Clinical Utilization Management & Analytics Specialist
Job Location:
Austin, TX - USA
Yearly Salary:
Posted:
Application Deadline:
Vacancies:
Job Summary
Requisition ID: req1456
Employment Type: Unclassified Regular Full-Time (URF)
Division: Health Contracts
Compensation: 108036.00 - 150000.00 Annual Salary
Job Closing: 10/30/2026 11:59PM CT
Location: TRS Headquarters Building 2
1900 Aldrich Street
Austin Texas 78723
United States
WHO WE ARE:
With the Health Division youll be joining a passionate team of self-motivated change agents united by our mission: driving to design the delivery of high-quality healthcare for nearly three-quarters of a million active and retired Texas public educators.
The healthcare industry is complex and were a team of problem-solvers who are up for the challenge. With a focus on innovation and collaboration to catalyze the market we spend nearly $4 billion annually on healthcare to make a difference in our members lives. With a career at TRS youll be empowered through a culture of continuous learning front-line decision-making coaching and mentorship to shape the future of our work while transforming healthcare delivery for 1 in 41 Texans.
The Clinical Utilization Management and Analytics Specialist performs senior-level clinical and analytic work to improve the value of TRS health programs. The position may be filled by a registered nurse physician or pharmacist with substantial healthcare analytics and utilization management experience. Using data from utilization management outcomes prior authorization provider quality and claims the position identifies avoidable or low-value spending and develops clinically appropriate opportunities to improve efficiency and quality of health care delivery. The position oversees the health plan administrators utilization management operations and works with internal stakeholders consulting firms and benefit vendors to reduce waste while protecting quality safety timely access and medically necessary care.
WHAT YOU WILL DO:
Utilization Management Oversight
Monitors and improves the health plan administrators utilization management operations including prior authorization concurrent and retrospective review case management appeals and transitions of care.
Designs custom utilization management requirements clinical protocols and performance expectations and assesses adherence to established criteria and industry standards.
Evaluates vendor performance and recommends actions to reduce waste improve affordability and outcomes and preserve access to medically necessary care.
Serves as a primary clinical and analytic resource for utilization management contract oversight including prior authorization medical necessity criteria peer-to-peer review site-of-care optimization exception management and escalated clinical issues.
Clinical Program Development and Implementation
Collaborates with TRS leadership consultants and health plan administrators to design and implement custom utilization management requirements and clinical programs.
Collaborates with health plan administrators to operationalize approved utilization management changes and ensure consistent implementation.
Evaluates proposed utilization management policies clinical criteria and program enhancements for alignment with TRS objectives.
Develops evidence-based initiatives that reduce unnecessary high-cost care and promote appropriate lower-cost settings and less-invasive high-quality alternatives.
Assists with developing contract requirements performance standards and clinical program specifications during procurements and contract amendments.
Coordinates implementation activities related to new utilization management initiatives clinical programs and regulatory changes.
Clinical Analysis and Strategic Support
Analyzes utilization management prior authorization site-of-care claims outcomes and provider data to identify cost drivers avoidable utilization low-value care variation clinically appropriate alternatives and opportunities to improve quality and total cost of care.
Evaluates proposed programs for their effects on quality access site-of-care member experience and total cost.
Develops reports dashboards business cases and recommendations that quantify opportunities and measure cost utilization quality and outcomes.
Provides clinical expertise for policy development vendor management activities audits procurements and special projects.
Performs related work as assigned.
WHAT YOU WILL BRING:
Required Education
Bachelors degree in nursing medicine pharmacy healthcare administration health informatics data analytics public health or a closely related field; or a professional degree required by licensure.
Required Experience
Five (5) years of progressively responsible experience in clinical practice provider or health plan utilization management or healthcare analytics.
Two (2) years of experience in utilization management prior authorization healthcare quality provider operations health plan operations or related clinical review activities including provider-health plan coordination.
Experience reviewing medical records and applying clinical criteria to healthcare services.
A masters degree or doctoral degree in a closely related field may be substituted on an equivalent year-for-year basis.
Required Registration Certification or Licensure
Current unrestricted professional license appropriate to the candidates clinical discipline such as RN physician (MD or DO) or pharmacist (RPh or PharmD) issued or recognized by Texas as applicable.
Preferred Qualifications
Certification in Utilization Management (CPUM) Case Management (CCM) Healthcare Quality (CPHQ) or related specialty.
Experience working with a health plan managed care organization third-party administrator Medicare program Medicaid program pharmacy benefit manager or governmental healthcare program.
Experience supporting healthcare vendor oversight audits or compliance activities.
Demonstrated experience using analytic tools to analyze and visualize utilization prior authorization claims provider site-of-care or outcomes data and communicate actionable findings.
Knowledge of public sector health benefit programs.
Knowledge of
Utilization management program design operations and industry standards.
Health plan administration and managed care operations.
Evidence-based clinical guidelines and utilization management methodologies.
Health care quality improvement and population health principles.
Health insurance benefit administration and provider reimbursement concepts.
Applicable federal and state healthcare regulations and accreditation standards.
Skill in
Vendor performance management and contract oversight.
Clinical program evaluation and implementation.
Advanced analysis of utilization prior authorization claims provider site-of-care outcomes and population health data.
Strategic problem solving and decision making.
Stakeholder engagement and relationship management.
Technical writing reporting and presentation development.
Ability to
Evaluate complex clinical and operational programs.
Translate clinical concepts into business and policy recommendations.
Influence outcomes through collaboration with vendors and stakeholders.
Analyze authorization patterns provider variation site of care utilization cost quality and outcomes to identify improvement opportunities.
Manage multiple projects and priorities simultaneously.
Military Occupational Specialty (MOS) Codes:
Veterans Reservists or Guardsmen with experience in the Military Occupational Specialty ( ) along with the minimum qualifications listed above may meet the minimum requirements and are highly encouraged to apply. Please contact Talent Acquisition at with questions or for additional information.
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