Behavioral Health Utilization Review Specialist - PaRC (Full-time Days)
Memorial Hermann
 Houston, TX

At Memorial Hermann, we're about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.

Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.

Job Summary

  • Full-time: M-F / 8-5
  • No weekends or holidays

This position is responsible for ensuring accurate and timely clinical review of behavioral health (substance dependence) cases for medical necessity based on federal, state and payer guidelines. This includes reviewing medical records, for pre-authorization, concurrent, discharge, retrospective and appeal medical necessity reviews utilizing knowledge of medical necessity criteria for all levels of behavioral health care from in-patient to out-patient admissions.

Job Description

Minimum Qualifications

Education:

  • Associates or Bachelors degree in Social Work; Behavioral Health; or related healthcare field; In lieu of degree; Licensed Chemical Dependency Counselor (LCDC)
  • or Licensed Vocational Nurse (LVN) with a minimum of one (1) year of working experience in utilization review, quality assurance or discharge planning plus meet additional qualifications as listed below

Licenses/Certification:

  • Current, unrestricted State of Texas Licensure as a Licensed Chemical Dependency Counselor (LCDC) or Licensed Clinical Social Worker (LCSW) or Licensed Professional Counselor (LPC)
  • Will also accept a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) with a minimum of three (3) years of clinical experience working in a psychiatric and/or substance abuse health care environment

Experience / Knowledge / Skills:

  • A minimum of (2) years of utilization review or quality assurance or discharge planning experience
  • Prior working experience in a drug or alcohol treatment facility
  • Basic knowledge with payer requirements for medical necessity reviews for different levels of care
  • Basic knowledge of TDI/ASAM medical necessity criteria, and must be able to clearly and effectively communicate this to payers
  • Knowledge of pre and post treatment review, concurrent review, appeals and denials (peer review process) DSM-IV and V
  • Excellent Microsoft Office skills in Word, Excel and Powerpoint and have the ability to learn other applications with ease
  • Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health“ through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principal Accountabilities

  • Reviews all case assignments for appropriateness of admissions using approved criteria.
  • Extends clinical appropriateness reviews through continued stay, under the direction of the departmental supervisor.
  • Reviews both concurrently and retrospectively of medical records and pertinent documentation in accordance with established policy and approved criteria.
  • Collection and analysis of data and reporting of results.
  • Takes appropriate follow-up action when established criteria for utilization of services are not met.
  • Identifies patients populations and monitors to assure that appropriate placement is secured.
  • Maintains appropriate documentation of clinical appropriateness reviews performed.
  • Acts as liaison with physicians and collaborates with health care team members in patient management rounds.
  • Approves cross service patient movements.
  • Performs onsite and/or telephonic/electronic; precertification, concurrent, discharge, retrospective and peer level review of inpatient and outpatient episodes of care.
  • Responsible for effective collaboration, communication and coordination among all responsible parties of an individual member's multidisciplinary health care team striving to eliminate fragmentation, duplication or gaps in treatment plans.
  • Refers all potential quality issues to the appropriate medical and hospital staff departments.
  • Assists with discharge planning activities of identified high risk patients and surveillance for patients requiring discharge planning referrals, and other discharge planning activities. Review and interview high risk patients and families to screen for discharge needs.
  • Takes appropriate follow-up action when established criteria for utilization of services are not met for example expedited/standard appeals.
  • Safeguards and ensures integrity of all data collected within the assigned department.
  • Acts as liaison with physicians and collaborates with health care team members in patient management rounds.
  • Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
  • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
  • Other duties as assigned.