BH Utilization Manager RN

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs: Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women Childrens Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more. Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

JOB

Behavioral Health Utilization Manager will perform concurrent and discharge reviews on assigned patients. Applies approved criteria for justification of admission and continued stay in the appropriate level of care. Notifies Medical Director regarding the review of medical records submitted by providers for peer to peer reviews.

Utilizes nationally recognized evidenced based clinical criteria, approved medical guidelines, and company policies. Provides timely responses of the outcome to the provider based on State policy. Assists in the ongoing development and maintenance of a database for tracking, trending and reporting of cases.

Job Specifications and Competencies: Verifies member eligibility, benefit coverage and facility contract status prior to processing authorization requests. Complies with established referral, precertification and authorization policies, procedures, and processes by related medical affairs for BH. Maintains knowledge of the designated referral and provider software systems.

Review telephonic and faxed clinical information to authorize medically necessary inpatient and outpatient care, utilizing nationally recognized evidenced based clinical criteria or approved medical guidelines. Accurately enters the required information into the managed care platform, adhering to BH UM and Appeals policies and procedures. Meets required performance metrics and quality standards for cases reviewed within established turnaround times.

Assists in the coordination of care of hospitalized members, medically complex members, and members with special needs if applicable. Participates in Community Rounds if applicable with Medical Director and coordinating with the Complex Case Management Team for post discharge referrals. Assists in discharge planning for members who are in psychiatric levels of care and provide appeals standards for denials.

Review any requests for extension of these services and if not meeting criteria, refer to the Medical Director. Makes appropriate referrals and follow up to other Community programs/departments. Assists co-workers with difficult cases through open discussion.

Communicates concerns that arise in these discussions to the Manager and/or Medical Director. Refers cases that do not meet criteria to Medical Director for review. Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans.

Other duties as assigned.

Education/Specialized Training/Licensure: Bachelor's degree in nursing. Current state Registered Nurse License. Work Experience (Years and Area): Two (2) years' experience in an acute psychiatric care setting.

Two (2) years' experience in utilization and appeal review in a managed care environment with Medicaid and Medicare members. Equipment Operated: Computer literate with knowledge of MS Word, MS Excel, Outlook, and telephone systems Work

Remote Other

Able to work independently under general instructions and working within a team environment, Able to apply the appeal and medical necessity criteria and use critical thinking