Manager l Utilization Management (Medicaid) job in TN | Anthem





SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s the foundation upon which we’re creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve.

Manager l Utilization Management (Inpatient) – Texas Medicaid (PS62128)

Location for External candidates: Texas residents only. [email protected]

The Manager I HCMS / Utilization Management (Texas Medicaid) is responsible for managing a team of physical and/or behavioral health practitioners responsible for coordinating member service, utilization, access, care management and/or concurrent review to ensure cost effective utilization of health, mental health, and substance abuse services for one or more member product populations of varying medical complexity ensuring the delivery of essential services that address the total healthcare needs of members. Primary duties may include, but are not limited to:

  • Manages and oversees team responsible in case finding and coordinating cases that involve comorbid conditions.
  • Coordinates service delivery to include member assessment of physical and psychological factors.
  • Responds to member, provider, and state complaints and inquiries.
  • Partners with providers to establish short and long-term goals that meet the member’s needs, functional abilities, and referral sources requirements.
  • Identifies members with potential for high-risk complications.
  • Reviews benefit systems and cost benefit analysis.
  • Evaluates medical, mental health and substance abuse service for cost containment.
  • Supports program compliance and assists in identifying opportunities to improve the customer service and quality outcomes.
  • Attends state meetings, implements state changes.
  • Supports quality initiatives and activities, including adherence to National Committee for Quality Assurance (NCQA) standards and HEDIS reporting.
  • Hires, trains, coaches, counsels, and evaluates performance of direct reports.


Minimum Requirements:

  • Requires a BA/BS; 5 years of experience in Health Care Management; or any combination of education and experience, which would provide an equivalent background.
  • Current active unrestricted RN license in the state of Texas required. Must be a Texas resident.
  • 1 year managed care industry work experience.
  • 1 year experience using FACETS.
  • 1+ years working in medical management interpreting and applying member contracts, member benefits, and managed care products.
  • 1+ years experience working with Interqual criteria, Milliman Care Guidelines, and/or Texas State Medicaid criteria (TMPPM.)
  • 1 year experience leading others formally (direct reports or Team Lead) or informally (SME, Project management, etc)
  • 5 years’ experience using MS Word and MS Excel.

Preferred Qualifications:

  • Proficient using FACETS
  • Experience using ACMP, HIP (Health Information Platform) and/or Care Compass a plus.
  • MSN, MPH, MPA, MSW or MBA with Health Care Concentration preferred.
  • Certified Case Manager Certification preferred.

Applicable to Colorado Applicants Only

Annual Salary Range*: $82,240 – $102,800

Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

  • The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company’s sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

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