Manager, Medical Management and Regulatory Operations - Remote

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.  

The Referral Navigator Supervisor is responsible for the day-to-day supervision, coordination, and operational performance of the Referral Navigator Department, including Home Health, Durable Medical Equipment (DME), Incomplete Referrals, Closed the Loop activities, authorization support functions, and other assigned Medical Management operations. This is a working supervisor position that actively participates in production activities while providing leadership, guidance, coaching, and operational support to Referral Navigators and, when applicable, Team Leads. The Supervisor is responsible for ensuring quality, productivity, timeliness, customer service, regulatory compliance, and achievement of departmental goals through effective workload management and staff development. This position is expected to exercise sound judgment, critical thinking, and operational problem-solving skills to identify practical solutions, improve workflow efficiency, and resolve operational issues independently whenever possible, escalating only those matters requiring higher-level leadership involvement.

If you are located in TX, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Performance
  • Provides direct supervision, leadership, coaching, and support for Referral Navigator staff and, when applicable, Team Lead personnel
  • Functions as a working supervisor by maintaining an active production workload while supporting daily departmental operations
  • Oversees operational activities related to Home Health, Durable Medical Equipment (DME), Incomplete Referrals, Closed the Loop processes, authorization support functions, and other assigned Medical Management workflows
  • Monitors work queues, inventory levels, staffing resources, production metrics, and operational performance indicators to ensure departmental goals are achieved
  • Provides guidance and support to staff regarding workflow processes, payer requirements, referral coordination, problem resolution, and customer service expectations
  • Coordinates daily workload assignments, queue balancing, staffing coverage, and operational priorities to support service level expectations
  • Participates in rotational phone queue coverage and ensures staff compliance with phone performance and customer service expectations
  • Conducts onboarding, training, coaching, mentoring, and performance development activities for assigned staff
  • Collaborates with clinics, providers, facilities, home health agencies, utilization management teams, medical reviewers, and operational partners to support efficient progression of member care requests
  • Promotes accountability, ownership, teamwork, professionalism, and service excellence throughout the department
• Compliance & Internal Quality
  • Ensures adherence to organizational policies, departmental procedures, accreditation standards, regulatory requirements, and payer-specific guidelines
  • Monitors quality performance through audits, case reviews, documentation reviews, and quality monitoring activities
  • Identifies quality concerns, process deficiencies, training opportunities, compliance risks, and operational issues and implements corrective actions as appropriate
  • Ensures accurate, timely, and audit-ready documentation of referral activities, communications, and operational actions
  • Supports implementation of departmental policies, workflow changes, quality initiatives, and corrective action plans
  • Conducts performance monitoring and provides feedback, coaching, and development opportunities to improve quality and consistency of work
  • Ensures staff maintain compliance with productivity, quality, documentation, and customer service expectations
• Timelines
  • Oversees daily operational performance to ensure referrals, home health requests, DME requests, authorization support activities, and Closed the Loop functions are completed within established turnaround times
  • Monitors aging inventories, pending requests, service levels, and operational workloads to identify and address delays before they impact patient care or customer service
  • Ensures timely follow-up on provider inquiries, clinic concerns, outstanding requests, and unresolved operational issues
  • Prioritizes departmental resources and workload distribution to maximize efficiency and support achievement of productivity and service goals
  • Holds staff accountable for meeting productivity standards, turnaround time expectations, attendance requirements, and operational commitments
  • Develops and implements workflow improvements that enhance efficiency, reduce delays, and improve overall departmental performance
• Other
  • Identifies opportunities for process improvement, workflow standardization, automation, and operational efficiency enhancements
  • Utilizes critical thinking, sound judgment, and available resources to resolve routine operational challenges independently before seeking leadership intervention
  • Researches operational issues, develops recommendations, and implements solutions designed to improve productivity, quality, member experience, and provider satisfaction
  • Assists leadership with reporting, staffing assessments, project implementation, operational planning, and departmental initiatives
  • Supports testing, implementation, and optimization of systems, workflows, and operational tools
  • Serves as a departmental resource for operational guidance, workflow interpretation, and problem resolution
  • Performs other duties as assigned to support departmental and organizational objectives

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
 

Required Qualifications:

• Graduate from accredited nursing program
• Registered Nurse or Licensed Vocational Nurse with state of Texas privileges
• 6+ years as a licensed vocational nurse (LVN) or Registered Nurse (RN)
• 4+ years of experience working within authorization modules, clinic charting systems, claims processing systems, or other operational areas of managed care
• 2+ years of management or supervisory experience in a managed care setting (physician office or hospital setting health plan, ACO, or other managed care setting)
• Knowledge of medical terminology, coding, COB payment, and prior authorization processes
• Demonstrate a working knowledge of industry standards processing
• Alpha/numeric data entry and advanced PC literacy
• Understanding of Health plan benefits and financial obligation interpretation
• Proven excellent verbal communication and time management skills
• Proven excellent interdepartmental coordination and communication

Preferred Qualifications:

• 3+ years of Kelsey-Seybold experience
• Experience with precertification and/or utilization management
• Benefit interpretation experience
• Knowledge of CPT & ICD 10 Coding methodologies and billing
• Knowledge of insurance payer specific prior authorizations requirements preferred
• Solid knowledge of HMO, PPO, and POS plan types
• Solid knowledge of Medicare and commercial health plans

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $18 - $32 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.