UM Manager

Provides Utilization Review and Quality Management activities for the Behavioral Health Division serving adults and children with mental illness and chemical dependency. Works closely with healthcare providers, insurance companies, and individuals to ensure that appropriate and necessary behavioral health services are being utilized effectively and efficiently. Essential Duties include the following:   

• Supports and Promotes LifePath Systems Mission: To serve individuals and families impacted by behavioral health, intellectual or developmental challenges, resulting in stronger communities. 
• Works under the supervision of the Utilization Management Director.
• Ensures consistent application of Utilization Management Guidelines.
• Coordinates and leads internal and external meetings as assigned.
• Ensures effective communication regarding UM operations and performance.
• Reviews and assesses the appropriateness and medical necessity to make authorization decisions, including but not limited to: Prospective, Concurrent and Retrospective Reviews within established timeframes.
• Has the ability to complete authorizations in other departments as needed.
• Makes initial adverse determinations and all clinical overrides (CORP) and exceptions in accordance with UM Guidelines, in consultation with the LBHA UM physician when indicated.
• Conducts UM activities for MCOs in accordance with MCO guidelines, including pre-authorizations and contractual forms within 2 business days or as set forth by the MCO.
• Ongoing monitoring, analyzing, evaluating, reporting, and recommending improvements in 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 regarding appeals, denials, higher level of care admission certification and concurrent review timeliness.
• Monitors provider adherence to UM Guidelines and provides consultation when needed.
• Ensures services provided meet the guidelines in accordance with the individual’s benefit plan(s).
• Participates in HHSC TA Calls as assigned.  Takes Notes and shares with applicable colleagues and management.  High priority items are shared immediately with management. 
• 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.
• Completes summaries and contractual/ required forms for in-network managed care organizations as assigned.

Education, Training and Experience (including licensure and certification)

• 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, preferred.

 

Knowledge, Skills, and 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 problems.
• 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.