Manager, Medical Management and Regulatory Operations - Remote

Work with one of the nation's leading health care organizations at Kelsey-Seybold Clinic, part of the Optum family of businesses. Join a nationally recognized team delivering coordinated and accountable care across 40+ locations in Houston, with over 900 medical providers in 65 specialties. This role offers the opportunity to drive higher quality care, patient satisfaction, and lower total costs in a multi-specialty clinic environment.

About the Role

The Referral Navigator Supervisor oversees 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 Team Leads.

Responsibilities

• Provide direct supervision, leadership, coaching, and support for Referral Navigator staff and Team Leads.
• Function as a working supervisor by maintaining an active production workload while supporting daily departmental operations.
• Oversee operational activities related to Home Health, DME, Incomplete Referrals, Closed the Loop processes, authorization support functions, and other assigned Medical Management workflows.
• Monitor work queues, inventory levels, staffing resources, production metrics, and operational performance indicators to ensure departmental goals are achieved.
• Provide guidance and support to staff regarding workflow processes, payer requirements, referral coordination, problem resolution, and customer service expectations.
• Coordinate daily workload assignments, queue balancing, staffing coverage, and operational priorities to support service level expectations.
• Participate in rotational phone queue coverage and ensure staff compliance with phone performance and customer service expectations.
• Conduct onboarding, training, coaching, mentoring, and performance development activities for assigned staff.
• Collaborate with clinics, providers, facilities, home health agencies, utilization management teams, medical reviewers, and operational partners to support efficient progression of member care requests.
• Promote accountability, ownership, teamwork, professionalism, and service excellence throughout the department.
• Ensure adherence to organizational policies, departmental procedures, accreditation standards, regulatory requirements, and payer-specific guidelines.
• Monitor quality performance through audits, case reviews, documentation reviews, and quality monitoring activities.
• Identify quality concerns, process deficiencies, training opportunities, compliance risks, and operational issues; implement corrective actions as appropriate.
• Ensure accurate, timely, and audit-ready documentation of referral activities, communications, and operational actions.
• Support implementation of departmental policies, workflow changes, quality initiatives, and corrective action plans.
• Conduct performance monitoring and provide feedback, coaching, and development opportunities to improve quality and consistency of work.
• Oversee 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.
• Monitor aging inventories, pending requests, service levels, and operational workloads to identify and address delays before they impact patient care or customer service.
• Ensure timely follow-up on provider inquiries, clinic concerns, outstanding requests, and unresolved operational issues.
• Prioritize departmental resources and workload distribution to maximize efficiency and support achievement of productivity and service goals.
• Hold staff accountable for meeting productivity standards, turnaround time expectations, attendance requirements, and operational commitments.
• Develop and implement workflow improvements that enhance efficiency, reduce delays, and improve overall departmental performance.
• Identify opportunities for process improvement, workflow standardization, automation, and operational efficiency enhancements.
• Utilize critical thinking, sound judgment, and available resources to resolve routine operational challenges independently before seeking leadership intervention.
• Research operational issues, develop recommendations, and implement solutions designed to improve productivity, quality, member experience, and provider satisfaction.
• Assist leadership with reporting, staffing assessments, project implementation, operational planning, and departmental initiatives.
• Support testing, implementation, and optimization of systems, workflows, and operational tools.
• Serve as a departmental resource for operational guidance, workflow interpretation, and problem resolution.
• Perform other duties as assigned to support departmental and organizational objectives.

Requirements

• Graduate from an accredited nursing program.
• Registered Nurse (RN) or Licensed Vocational Nurse (LVN) with state of Texas privileges.
• 6+ years of experience 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, hospital setting, health plan, ACO, or other managed care environment).
• Knowledge of medical terminology, coding, coordination of benefits (COB) payment, and prior authorization processes.
• Demonstrated 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 authorization requirements.
• Solid knowledge of HMO, PPO, and POS plan types.
• Solid knowledge of Medicare and commercial health plans.

Benefits

In addition to competitive pay, we offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).

Pay

The hourly pay for this role will range from $18 - $32 per hour based on full-time employment, depending on factors such as local labor markets, education, work experience, and certifications.

Schedule

If located in Texas, you will have the flexibility to work remotely.