GENERAL DESCRIPTION

Provides Utilization Review and Quality Management activities for a Behavioral Health Agency serving adults and children with mental illness and chemical dependency. Essential Duties include:

• Ensures consistent application of UR Guidelines.
• Works under the supervision of the Director of UM/QM and ensures effective communication regarding UR operations and performance.
• Reviews information to make authorization decisions including but not limited to: Prospective, Concurrent and Retrospective Reviews.
• Ongoing monitoring, analyzing, evaluating, reporting, and recommending improvements in Continuity of Care and Utilization Review and organizational processes and functions.
• Monitor, identify, analyze and report patterns or over-utilization, under-utilization and other utilization problems that compromise care of inappropriately utilized resources.
• Ensure compliance with all performance measures in regard to appeals, denials, higher level of care admission certification and concurrent review timeliness.
• Monitors provider adherence to COC and UR Guidelines and provides consultation when needed.
• Ensures services provided meet the guidelines in accordance with client benefit plans.
• Maintains knowledge of local resources for outside referrals.
• Participates in fidelity audits, summarizes findings, recommends quality improvements, and provides trainings as needed to meet required standards.
• Does not provide, nor supervises anyone who provides direct services.
• Other duties as assigned

EDUCATION, TRAINING, & EXPERIENCE

• Licensed Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), or Licensed Marriage and Family therapist (LMFT) and is licensed in Texas.
• Has at least five years of clinical experience in the treatment of individuals with serious mental illness including experience in an acute care setting.
• Has at least five years of experience participating as a member of a treatment team that develops and monitors treatment plans for individuals with chronic and serious mental illness.
• Has at least one year of experience supervising mental health providers.

ESSENTIAL TASKS & STANDARDS

• Conducts utilization reviews and granting and denying authorizations for all MH and SUD LOCs and services for the indigent population.
• Provides LBHA utilization management activities for external MCO’s to ensure that appropriate services are authorized for reimbursement through designated managed care companies.
• Maintain current UM processes in response to Managed Care requirements, including RFT, authorizations, denials and clinical updates.
• Ensure that all UM essential tasks are completed in a timely and efficient manner.
• Provides support for quality, regulatory and compliance activities to ensure that services provided are in accordance with all regulatory and accreditation requirements.
• Participates in data collection and analysis for daily operations purposes as well as for quality measures (1115 Waiver, CCBHC, MIPS, etc).
• Understands and promotes trauma informed care practices.

KNOWLEDGE, SKILLS, & ABILITIES

• Demonstrated ability to apply to UM/QM Guidelines and processes consistently.
• Demonstrated ability to foster collaborative relationships with key interfacing agency staff.
• Self-starter who works closely with all team members and takes initiative in completing tasks.
• Demonstrated ability to ensure effective communication regarding UM/QM operations, performance, and
• Acumen in reviewing information to make authorization decisions including but not limited to: Prospective, Concurrent and Retrospective Reviews.
• Works under general supervision with moderate latitude for the use of initiative and independent judgment.
• Knowledge of the social services system and the ability to guide staff in connecting individuals with appropriate services.
• Knowledge of the current version of the Diagnostic Statistical Manual of Mental Disorders (DSM).
• Organized, detail oriented, computer proficient, and able to write clearly and professionally.
• Ability to respond to individuals with patience, empathy, and understanding.

Excellent communication and listening skills.

CERTIFICATES, LICENSES, & REGISTRATIONS

• Must have valid Texas Driver License and a good driving record.
• Must be able to pass a criminal background check.
• Must be able to complete all LifePath Systems training.
• Must be able to provide at least 3 professional or educational references.

BENEFITS

Salary Range: $ 72,000 per year

Shift Hours: Monday-Friday 8am to 5pm

We offer a competitive salary and comprehensive benefit package including medical, dental, FSA, 401(k), voluntary benefits, Paid Time Off (PTO) and Extended Illness (EI), and Holidays.

If interested, please complete an online application at LifePath Systems Job Openings and attach your resume

Equal Opportunity Employer

LifePath Systems is an equal opportunity employer (Minorities/Females/Disabled/Veterans). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, veteran status, or any other basis protected by applicable federal, state, or local law.

To read more about this, view the EEO is the Law poster and this EEO is the Law Poster Supplement.