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Utilization Review Manager Jobs in Kyle, TX (NOW HIRING)

Humana

Compliance UM Nurse (Wed - Sun)

Austin, TX · On-site

Become a part of our caring community The Compliance Nurse 2 reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent ...

University Health

Nurse Case Manager

Seguin, TX · On-site

$32.50 - $51/hr

Work experience in case management, utilization review or hospital quality is preferred. LICENSURE/ CERTIFICATIONS Current licensure as a Registered Nurse with the Texas State Board of Nurse ...

University Health

Nurse Case Manager

Seguin, TX · On-site

$30.25 - $51/hr

Work experience in case management, utilization review or hospital quality is preferred. LICENSURE/ CERTIFICATIONS Current licensure as a Registered Nurse with the Texas State Board of Nurse ...

CAPPS

GLO - Contract Administration Manager I

Austin, TX · On-site

$7.9K - $9.5K/mo

The report must summarize therapy spend, utilization trends, SCD70 therapy volume, review results ... Property Management and Procurement . How to Apply: To be considered, please complete a State of ...

Evolent

Physician Reviewer-Radiology (Full-Time)

Austin, TX · On-site

$95 - $96/hr

As a FMD, Radiology you will be a key member of the utilization management team. We can offer you a ... Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review ...

Evolent

Physician Reviewer-Radiology (Part Time)

Austin, TX · On-site

$95 - $100/hr

As a FMD, Radiology you will be a key member of the utilization management team. We can offer you a ... Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review ...

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All JobsUtilization Review JobsUtilization Review Manager JobsUtilization Review Manager Jobs in Kyle, TX

Utilization Review Manager information

See Kyle, TX salary details

$37.4K

$87.3K

$160.7K

How much do utilization review manager jobs pay per year?

As of Aug 12, 2026, the average yearly pay for utilization review manager in Kyle, TX is $87,330.00, according to ZipRecruiter salary data. Most workers in this role earn between $57,100.00 and $105,100.00 per year, depending on experience, location, and employer.

Is utilization review a stressful job?

Utilization review managers oversee the assessment of healthcare services to ensure appropriate and efficient care, which can involve high workloads and strict deadlines, leading to stress. The job requires strong organizational skills, attention to detail, and the ability to handle complex cases, which may contribute to job-related stress for some individuals.

What are some common challenges faced by utilization review managers in balancing patient care and cost efficiency?

Utilization Review Managers often encounter the challenge of ensuring patients receive appropriate care while also adhering to insurance and regulatory guidelines that emphasize cost efficiency. This requires strong analytical skills to assess clinical information and make fair determinations, often under tight deadlines and with incomplete data. The role also involves frequent communication with physicians, payers, and case managers to resolve disagreements and clarify criteria, making negotiation and diplomacy essential. Staying updated on changing healthcare regulations and payer requirements can add to the complexity, but it also provides opportunities for professional growth and leadership within healthcare administration.

What are the key skills and qualifications needed to thrive as a utilization review manager?

To thrive as a Utilization Review Manager, you need a solid background in healthcare management, clinical knowledge (often as an RN or healthcare professional), and experience with utilization review processes. Familiarity with case management software, electronic health records (EHRs), and certifications such as Certified Case Manager (CCM) or Certified Professional in Utilization Review (CPUR) are often expected. Strong analytical thinking, attention to detail, leadership, and effective communication are crucial soft skills for success in this role. These skills ensure appropriate resource use, regulatory compliance, and coordinated patient care, which are vital for both healthcare quality and operational efficiency.

What is the difference between Utilization Review Manager vs Utilization Review Coordinator?

AspectUtilization Review ManagerUtilization Review Coordinator
CertificationsTypically requires certifications like CCM or ACUMay require similar certifications but often less advanced
Work EnvironmentSupervises review teams, manages processes in healthcare or insurance settingsPerforms case reviews, supports the review process under supervision
Employer & IndustryHospitals, insurance companies, healthcare organizationsInsurance companies, healthcare providers, third-party administrators

The Utilization Review Manager oversees review teams and manages utilization review processes, focusing on policy compliance and efficiency. The Utilization Review Coordinator supports the review process by conducting case assessments and assisting managers. While both roles require similar certifications and work in related environments, the manager holds a supervisory position with broader responsibilities.

What does a utilization review manager do?

A Utilization Review Manager oversees the process of evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. They ensure that patient care adheres to established guidelines and that healthcare resources are used effectively. Their duties typically include leading a team of reviewers, collaborating with healthcare providers, ensuring compliance with regulations, and making recommendations on care authorization. The goal is to balance quality patient care with cost-effective resource management.
What are popular job titles related to Utilization Review Manager jobs in Kyle, TX? For Utilization Review Manager jobs in Kyle, TX, the most frequently searched job titles are:
What job categories do people searching Utilization Review Manager jobs in Kyle, TX look for? The top searched job categories for Utilization Review Manager jobs in Kyle, TX are:
What cities near Kyle, TX are hiring for Utilization Review Manager jobs? Cities near Kyle, TX with the most Utilization Review Manager job openings:
Utilization Review Manager jobs near you

Clinical Quality & Utilization Review Specialist

Central Health

Austin, TX • On-site

Full-time

Re-posted 15 days ago

Job description

Overview
Under the supervision of the Director of Utilization Management, the Clinical Quality and Utilization Review Specialist performs a dual role encompassing utilization management and peer review. This position is responsible for assessing the medical appropriateness, efficiency, and quality of healthcare services across inpatient and outpatient settings, including authorization review and utilization oversight. In parallel, the RN coordinates peer review activities including screening, reviewing, and preparing cases and facilitating Root Cause Analyses (RCAs) to evaluate clinical performance and identify opportunities for improvement. The Clinical Quality and Utilization Review Specialist partners closely with physicians, advanced practice providers (APPs), and interdisciplinary teams to support evidence-based decision-making, optimize patient outcomes, and drive continuous improvement. Serving as a key liaison among providers, compliance, nursing, quality, and leadership, this role ensures that findings from utilization reviews, peer review, and quality activities translate into meaningful and sustainable improvements in clinical practice and systems of care.
This role works in close collaboration with medical staff leadership and the Medical Executive Board (MEB) designee to support peer review, utilization management, patient safety, and quality functions in accordance with medical staff bylaws, organizational policies, and accreditation standards.
**This role is located in Austin, Tx. Only those that reside in the greater Austin/Travis County area will be considered for this position**
Responsibilities
JOB FUNCTIONS:
Essential Functions:
Peer Review & Clinical Quality:
  • Coordinate and facilitate peer review activities in alignment with medical staff bylaws, organizational policies, and accreditation standards.
  • Screen, review, and prepare cases for peer review committees, ensuring completeness, objectivity, and readiness for evaluation.
  • Partner with physician and APP reviewers to support fair, consistent, and evidence-based evaluation of clinical care.
  • Track, document, and communicate peer review outcomes, ensuring timely feedback, follow-up, and provider education.
  • Maintain strict confidentiality of peer review activities and records in accordance with legal and regulatory requirements.
  • Support preparation and coordination of clinical quality and peer review committee meetings and associated materials.

Quality Improvement & Patient Safety:
  • Participate in Root Cause Analyses (RCAs) for sentinel events, near misses, and high-risk occurrences.
  • Collaborate with interdisciplinary teams to identify contributing factors, system vulnerabilities, and opportunities for improvement.
  • Support development, implementation, and monitoring of corrective action plans.
  • Lead or support quality improvement initiatives informed by utilization data, peer review findings, and organizational priorities.
  • Apply evidence-based methodologies (e.g., PDSA, Lean, Six Sigma) to drive measurable improvements in care quality and efficiency.
  • Prepare and deliver reports, dashboards, and presentations on utilization, peer review, and quality outcomes.
  • Provide education and coaching to staff and providers on quality improvement principles and findings.

Utilization Management:
  • Perform comprehensive utilization reviews and manage authorizations for inpatient and outpatient services, including skilled nursing, home health, durable medical equipment (DME), and other clinical programs.
  • Assess medical necessity, appropriateness of care, and level of service using established clinical criteria and guidelines.
  • Review providers' contracts and approve healthcare services as specified in these contracts.
  • Collaborate with physicians, case managers, social workers, and care teams to ensure coordinated, patient- centered care and optimal outcomes.
  • Conduct telephonic and email-based outreach to the provider community, as appropriate, as part of the utilization review work.
  • Obtain, review, and analyze clinical documentation to support authorization decisions and ensure regulatory compliance.
  • Communicate determinations and recommendations clearly and professionally with internal and external stakeholders.
  • Ensure accurate and timely documentation in the electronic health record, or utilization review database, maintaining compliance with organizational and regulatory standards.
  • Participate in the appeals process as needed, providing clinical expertise and supporting documentation.
  • Monitor utilization trends and identify opportunities to improve efficiency and care delivery.
  • Participate in the utilization review/utilization management committee and effectively contribute to the functioning of the committee work.

Collaboration & Organizational Support:
  • Partner with the Medical Executive Board (MEB) designee and medical staff leadership to support peer review, quality, and patient safety activities in alignment with medical staff bylaws and organizational priorities.
  • Exercise independent judgment in coordinating peer review processes, ensuring consistency, fairness, and adherence to established clinical standards.
  • Support and coordinate committees and workgroups related to utilization management, peer review, and clinical quality, including preparation of materials and follow-up on action items.
  • Serve as a liaison between administrative leadership, medical staff, and interdisciplinary teams to advance utilization and quality initiatives.
  • Develop and maintain collaborative working relationships across internal teams and external partners.
  • Promote a culture of safety, accountability, professionalism, and continuous improvement.
  • Demonstrate commitment to organizational mission, values, and health equity goals.

Knowledge, Skills and Abilities:
  • Strong clinical judgment with the ability to assess medical necessity and appropriateness of care across care settings.
  • Knowledge of utilization management processes, healthcare regulations, and accreditation standards.
  • Understanding of peer review principles, confidentiality requirements, and quality improvement methodologies.
  • Ability to analyze clinical data, identify trends, and translate findings into actionable insights.
  • Skill in facilitating discussions with physicians and interdisciplinary teams, including sensitive or complex topics.
  • Strong organizational and time management skills, with the ability to manage multiple priorities in a dynamic environment.
  • Excellent written and verbal communication skills, including report and presentation development.
  • Ability to maintain confidentiality and exercise discretion when handling sensitive information.
  • Proficiency in electronic health records and Microsoft Office Suite.
  • Ability to build strong relationships and work collaboratively across multidisciplinary teams.
  • Commitment to health equity, diversity, and inclusion in care delivery and organizational practices.
  • Demonstrated professionalism, accountability, and adaptability in a complex healthcare environment.

Qualifications
QUALIFICATIONS:
Education:
Bachelor's Degree (higher degree accepted) in Nursing (BSN) Required Or Doctoral or Professional Degree Advanced Practice Provider- Required
Work Experience:
(3) Three years of hands-on, clinical experience in the nursing or a related healthcare field, -Required
PLUS the following:
Minimum of two (2) years of experience in utilization management, case management, care coordination, or clinical program development in the managed care setting or at a health system -Required
Experience in peer review, quality improvement, or patient safety initiatives during the last five (5) years of professional. -Required
Licenses and Certifications:
RN - Registered Nurse - State Licensure - Unrestricted Registered Nurse License in the State of Texas Upon Hire -Required

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