Job Description

Clinical Utilization Management & Analytics Specialist

Requisition ID: req1456

Employment Type: Unclassified Regular Full-Time (URF)

Division: Health Contracts

Compensation: 108,036.00 - 150,000.00, 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, you’ll 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 we’re 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, you’ll 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 administrator’s 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 administrator’s 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

• Bachelor’s 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 master's 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 candidate’s 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 ( https://www.trs.texas.gov/files/trs-military-crosswalk.xlsx ) along with the minimum qualifications listed above may meet the minimum requirements and are highly encouraged to apply. Please contact Talent Acquisition at careers@trs.texas.gov with questions or for additional information.

To view all job vacancies, visit www.trs.texas.gov/careers or www.trs.csod.com/careersite.

For more information, visit www.trs.texas.gov.