Utilization Review Jobs in Spring, TX (NOW HIRING)

Nexus Health Systems is seeking an experienced and strategic healthcare leader to serve as the Corporate Director of Care Management. This role provides operational and clinical oversight for all case management, utilization review, discharge planning, and care coordination functions across multiple Nexus facilities. The Corporate Director will partner closely with executive leadership, physicians, nursing teams, and interdisciplinary departments to drive exceptional patient outcomes, regulatory compliance, patient throughput, and financial performance.

This position plays a critical role in supporting patients with neurodevelopmental disorders and co-occurring complex behavioral and medical conditions across the continuum of care.

Nexus Health Systems is a multi-facility healthcare organization specializing in complex medical, neurobehavioral, rehabilitation, and behavioral healthcare services for pediatric and adult populations. Our mission-driven team is committed to delivering compassionate, evidence-based care while improving quality of life for patients and families.

The Corporate Director of Care Management will lead system-wide care management operations including utilization review, discharge planning, transition of care initiatives, and interdisciplinary care coordination. This leader will standardize workflows, optimize length of stay, strengthen payer relationships, and ensure compliance with CMS Conditions of Participation, accreditation standards, and organizational policies.

• Lead and standardize care management operations across assigned facilities
• Oversee utilization review, discharge planning, care coordination, and transition of care processes
• Ensure compliance with CMS Conditions of Participation, Joint Commission/DNV standards, and URAC principles
• Establish and oversee Utilization Management Committee operations
• Collaborate with physician advisors regarding medical necessity determinations and documentation quality
• Implement InterQual® criteria for admission status, continued stay reviews, and discharge readiness
• Promote Neurodevelopmental Disabilities (NDD)-informed care practices throughout care management workflows
• Support interdisciplinary collaboration to improve patient throughput and continuity of care

• Monitor regulatory compliance related to utilization review and discharge planning
• Lead performance improvement initiatives and accreditation readiness efforts
• Conduct audits related to documentation, appeals, timeliness, and care coordination practices
• Promote patient safety and continuous quality improvement across facilities
• Ensure accurate documentation supporting medical necessity and fiscal reimbursement

• Champion person-centered discharge planning and patient advocacy initiatives
• Support sensory-friendly environments and communication accommodations for neurodiverse patients
• Assist patients and families with community resources, financial assistance, and care transitions
• Collaborate with patients, caregivers, and healthcare teams to prevent fragmentation of services

• Provide mentorship, coaching, and operational guidance to care management teams
• Oversee recruitment, onboarding, and professional development for department staff
• Develop competency pathways and leadership development programs
• Encourage professional certification attainment including CCM, ACM-RN, ACM-SW, and CPHQ
• Facilitate annual education and training related to InterQual®, CMS regulations, and best practices

• Optimize length of stay and reduce avoidable days through proactive utilization management
• Monitor throughput, payer denials, appeals, case mix, and departmental performance metrics
• Develop and manage departmental budgets and resource allocation
• Collaborate with payers and physician advisors to support efficient, cost-effective care delivery
• Ensure equitable care management services regardless of payer source

• Bachelor of Science in Nursing (BSN) required
• Master of Science in Nursing (MSN) required

• Minimum 7 years of progressive leadership experience in hospital case management
• Multi-site leadership experience required
• Strong background in utilization review, discharge planning, and care coordination
• Experience working with neurodevelopmental, behavioral health, and medically complex populations strongly preferred
• Knowledge of CMS regulations, Joint Commission/DNV standards, and utilization management practices

• Current and valid Texas Registered Nurse (RN) license required
• Case Management Certification required (ACM, CCM, CMGT, FAACM, or equivalent)
• Certification must be obtained within two years of hire if not currently held

• Expert knowledge of CMS Conditions of Participation and utilization management principles
• Proficiency with InterQual® criteria and medical necessity determinations
• Strong leadership, communication, and interdisciplinary collaboration skills
• Experience with EHR systems and healthcare analytics
• Exceptional organizational, strategic planning, and operational management abilities
• Compassionate, patient-centered leadership style with strong advocacy skills

• Mission-driven healthcare organization focused on improving lives
• Collaborative executive leadership environment
• Opportunity to shape and standardize care management across multiple facilities
• Meaningful work supporting medically and behaviorally complex patient populations
• Competitive compensation and comprehensive benefits package
• Professional growth and leadership development opportunities