SPECIALIST MH UTILIZATION RISK MANAGEMENT

Description

Are you looking for a purpose-driven career? At Metrocare, we serve our neighbors with developmental or mental health challenges by helping them find lives that are meaningful and satisfying.

Metrocare is the largest provider of mental health services in North Texas, serving over 55,000 adults and children annually. For over 50 years, Metrocare has provided a broad array of services to people with mental health challenges and developmental disabilities. In addition to behavioral health care, Metrocare provides primary care centers for adults and children, services for veterans and their families, accessible pharmacies, housing, and supportive social services. Alongside clinical care, researchers and teachers from Metrocare’s Altshuler Center for Education & Research are advancing mental health beyond Dallas County while providing critical workforce to the state.

The MH Utilization/Risk Management Specialist (MHU/RMS) is responsible for providing the responsibilities of the UM process related to denials, appeals, eligibility and authorization of services for individuals with Mental Health Issues (MH) and/or co-occurring disorders of Intellectual and Developmental Disabilities (IDD) and Substance Abuse. This position works collaboratively with internal providers, Managed Care Organizations (MCO), and the Quality Management Coordinator to ensure services meet clinical standards as specified by HHSC and the payer source(s). This position will assist in providing surveillance in the areas Risk Management relative to Infection Control and Cultural Competency and Inclusion.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

The essential functions listed here are representative of those that must be met to successfully perform the job.

• Assesses, plans, implements, and evaluates the Utilization Review (UR) process for services provided by Metrocare Services.
• Provides analytical data based on the utilization of services and the UR process to ensure risk management compliance.
• Collects, reviews, analyzes, and reports data in accordance with Quality Management standards for risk management (Infection Control), cultural competency/inclusion and quality improvement for designated programs.
• Completes internal utilization reviews of Level of Care and Recovery Plans.
• Monitors data affecting utilization of services and medical necessity issues.
• Coordinates and implements appeal processes to ensure customers receive needed and appropriate services.
• Coordinates and implements authorization processes, especially towards denials and appeals, as required to ensure that customers receive needed and appropriate services in support of meeting personal and organizational outcomes.
• Conducts audits of customer records and documents results to provide quality assurance and effective resource management.
• Attends meetings, trainings and staffing as scheduled to share information and ensure training and licensure requirements are being met.
• Assists the supervisor or other Metrocare staff with special projects or assignments following appropriate guidelines in order to ensure the efficient operation of Metrocare in support of meeting personal and organizational outcomes.
• Adheres to all state and federal regulations regarding confidentiality of customer identifying information for UM purposes.
• Performs other duties, as required, or directed in accordance with the needs of Metrocare.

COMPETENCIES:

The competencies listed here are representative of those that must be met to successfully perform the essential functions of this job.

• Conducts job responsibilities in accordance with the ethical standards of conduct, state contract, appropriate professional standards, and applicable state/federal laws

• Analytical skills, professional acumen, business ethics, thorough understanding of continuous improvement processes, problem solving, respect for confidentiality, and excellent communication skills.
• Effective verbal and written communication skills.
• Able to apply psychiatric clinical standards to a Utilization Review process.
• Able to interact with the public to teach and assist in outcomes that are most appropriate for individuals receiving services.
• Ability to review and analyze utilization data.
• Able to organize, prioritize a variety of assignments and manage time effectively.
• Able to work autonomously and make rational, and independent decisions.
• Able to maintain an effective working relationship with other employees and the public.
• Able to assist agency in optimizing third party payer reimbursements.
• Knowledge of Risk Management (Infection Control) and/or the ability to acquire the knowledge needed to perform the responsibilities associated with risk.
• Able to ensure safety and risk measures to ensure compliance and mitigate exposure.
• Able to assist agency in contract compliance and meeting Medicare and Medicaid standards in areas that affect utilization of services.
• Knowledge of Medicare, Medicaid, Department of State Health Services (DSHS) and Texas Administrative Code (TAC) regulations in areas that affect Utilization Management and Risk Management.
• Demonstrated experience in establishing rapport with health care professionals and health care administration and clear understanding of Utilization Management and Quality Management issues.

QUALIFICATIONS

EDUCATION AND EXPERIENCE:

• Masters degree in Human Services field, required; with applicable license, LCSW, LPC, LMSW or BSN RN.
• Minimum of two (2) years full time experience in the field of mental health, intellectual and/or developmental disabilities, and utilization management is required. Knowledge of risk management is an asset.

MATHEMATICAL SKILLS:

• Basic math skills required.
• Ability to work with reports and numbers.
• Ability to calculate moderately complex figures and amounts to accurately report activities and budgets.

REASONING ABILITY:

• Ability to apply common sense understanding to carry out simple one or two-step instructions. Ability to deal with standardized situations with only occasional or no variables.

COMPUTER SKILLS:

• Use computer, printer, and software programs necessary to the position (i.e., Word, Excel, Outlook, and PowerPoint).
• Ability to utilize Internet for resources.

CERTIFICATIONS, LICENSES, REGISTRATIONS:

• Current State of Texas Driver License or if you live in another state, must be currently licensed in that state. If licensed in another state, must obtain Texas Driver License within three (3) months of employment.
• Liability insurance required if employee will operate personal vehicle on Center property or for Center business. Must be insurable by Centers liability carrier if employee operates a Center vehicle or drives personal car on Center business. Must have an acceptable driving record.
• LCSW, LMSW or LPC; or BSN RN

Metrocare couldn’t have a great employee-first culture without great benefits. That’s why we offer a competitive salary, exceptional training, and an outstanding benefits package:

• Medical/Dental/Vision
• Paid Leave
• Paid Holidays
• Employee Assistance Program
• Retirement Plan, including employer matching
• Health Savings Account, including employer matching
• Professional Development Allowance up to $1500 per year
• Bilingual Stipend – up to 6% of the base salary
• Many other benefits

Equal Employment Opportunity/Affirmative Action Employer

Tobacco-Free Facilities - Metrocare is committed to promoting the health, well-being, and safety of Metrocare team members, guests, and individuals and families we serves while on the facility campuses. Therefore, Metrocare facilities and grounds are tobacco-free.

No Recruitment Agencies Please

Qualifications

Salary : $1,500