BH Utilization Manager RN

About Us

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
• Children’s 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 including 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.

About the Role

As a Behavioral Health Utilization Manager, you will perform concurrent and discharge reviews on assigned patients. You will apply approved criteria for justification of admission and continued stay in the appropriate level of care, and notify the Medical Director regarding the review of medical records submitted by providers for peer-to-peer reviews. You will utilize nationally recognized evidence-based clinical criteria, approved medical guidelines, and company policies to provide timely responses to providers based on State policy. Additionally, you will assist in the ongoing development and maintenance of a database for tracking, trending, and reporting of cases.

Responsibilities

• Verify member eligibility, benefit coverage, and facility contract status prior to processing authorization requests
• Comply with established referral, precertification, and authorization policies, procedures, and processes related to behavioral health medical affairs
• Maintain knowledge of designated referral and provider software systems
• Review telephonic and faxed clinical information to authorize medically necessary inpatient and outpatient care, utilizing nationally recognized evidence-based clinical criteria or approved medical guidelines
• Accurately enter required information into the managed care platform, adhering to behavioral health utilization management and appeals policies and procedures
• Meet required performance metrics and quality standards for cases reviewed within established turnaround times
• Assist in the coordination of care for hospitalized members, medically complex members, and members with special needs, if applicable
• Participate in Community Rounds, if applicable, with the Medical Director and coordinate with the Complex Case Management Team for post-discharge referrals
• Assist in discharge planning for members in psychiatric levels of care and provide appeals standards for denials
• Review requests for extension of services and, if not meeting criteria, refer to the Medical Director
• Make appropriate referrals and follow up with other Community programs/departments
• Assist co-workers with difficult cases through open discussion and communicate concerns to the Manager and/or Medical Director
• Refer cases that do not meet criteria to the Medical Director for review
• Actively contribute to the achievement of departmental goals, including specific departmental process improvement plans
• Perform other duties as assigned

Requirements

• Bachelor's degree in nursing
• Current state Registered Nurse License
• 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

Skills

• Computer literate with knowledge of MS Word, MS Excel, Outlook, and telephone systems
• Able to work independently under general instructions and within a team environment
• Able to apply appeal and medical necessity criteria and use critical thinking

Schedule

Remote