Job Details

Job Location
Cantex Corporate - Carrollton, TX

Position Type
Full Time

Job Category
Ancillary Services

Description

Position Summary

The Utilization Manager will be responsible for overseeing and executing all aspects of utilization management, including medical necessity reviews, authorization workflows, and care coordination. This role is critical to ensuring that services provided to members are appropriate, cost-effective, and compliant with regulatory standards.

Qualifications

Key Responsibilities

• Conduct timely utilization reviews and determine medical necessity using evidence-based criteria.
• Manage inpatient and outpatient authorization processes, including denials and peer-to-peer reviews.
• Monitor utilization trends and identify opportunities for cost containment and quality improvement.
• Collaborate with internal departments (Claims, Appeals, Network, Compliance) to support seamless care coordination.
• Serve as a clinical resource for providers and facilities regarding UM policies and procedures.
• Ensure compliance with CMS, AAAHC, and state regulatory requirements.
• Participate in Quality Improvement and Compliance Committee meetings to review utilization data and outcomes.
• Support transitions of care and continuity planning for high-risk members.
• Maintain confidentiality and uphold ethical standards in all UM activities.

Qualifications

• RN, LCSW, LPC, LMFT, or PA licensed in Texas (required).
• Minimum 3 years of experience in utilization management or managed care.
• Familiarity with Medicare Advantage and Special Needs Plans (SNPs) preferred.
• Strong analytical, communication, and organizational skills.
• Experience with UM platforms and electronic health records.
• Ability to work independently and collaboratively in a fast-paced environment.

Preferred Attributes

• Prior experience in in-house UM operations.
• Knowledge of ProCare Advantage policies and workflows.
• Commitment to member-centric, trauma-informed care.

Diversity, Equity, and Inclusion are at the heart of Cantex. We are committed to a culture that respects our differences and values the contributions of all people.

We are an Equal opportunity employer; We offer an excellent benefit plan to include 401K with match, CEU reimbursement, vacation, sick, holidays, medical, dental, and supplemental insurance Plans as well as a Highly competitive compensation package.

Please visitcantexcc.comfor more information on this location.