Metrocare Services

Utilization/Risk Management Specialist

US-TX-Dallas
1 month ago
ID
2017-2586
# of Openings
1
Category
Clinical
Type
Regular Full-Time

Overview

Working for Metrocare isn’t just a job. It’s a career where your skills and passion for delivering quality care make a positive difference to the individuals that we serve.

 

Metrocare is the largest provider of mental health services in Dallas County, serving more than 52,000 adults and children annually. For more than fifty (50) years, Metrocare has provided an array of services available to people with mental and developmental disabilities. In addition to behavioral health services, Metrocare provides primary care centers for adults and children, accessible pharmacies, housing and supportive social services. Through the Altshuler Center for Education & Research and our software initiative, XenatiX, we are advancing mental health beyond Dallas County.

 

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 consumers with Mental Health Issues (MH) and/or co-occurring disorders of Intellectual and Developmental Disabilities (IDD) and Substance Abuse. The MHU/RMS will work with internal providers, Managed Care Organizations (MCO), and the Quality Management Coordinator to insure services meet clinical standards as specified by the payer source(s). This position will also provide surveillance in the area of Risk Management (RM).

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 insure risk management compliance.
  • 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 in order to share information and ensure training and licensure requirements are being met.
  • Assists the supervisor or other Center staff with special projects or assignments following appropriate guidelines in order to ensure the efficient operation of the center in support of meeting personal and organizational outcomes.
  • Adheres to all state and federal regulations regarding confidentiality of customer identifying information for UM purposes.
  • Collects, reviews, analyzes and reports data in accordance with Quality Management with an emphasis on risk management for designated programs.
  • Performs other duties, as required or directed in accordance with agency needs

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 consumers.
  • 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 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:

  • Master’s degree in Human Services field, with applicable license LCSW, LMSW or LPC; or BSN – RN.
  • Minimum of two (2) years full time experience in the field of mental health, intellectual and 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. 

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 (e.g., Word, Excel, Outlook, and PowerPoint).
  • Ability to utilize Internet for resources.

CERTIFICATIONS, LICENSES, REGISTRATIONS: 

  • LCSW, LMSW or LPC; or BSN – RN
  • 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 Center’s liability carrier if employee operates a Center vehicle or drives personal car on Center business. Must have an acceptable driving record

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
  • 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 calls from staffing agencies or independent recruiters

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