Behavioral Health Utilization Review Nurse - Texas Behavioral Health Center

UT Southwestern Medical Center • Dallas, TX

5d • Onsite

About The Position

The Inpatient Behavioral Health Utilization Management Nurse performs utilization management activities for patients receiving services at UT Southwestern's acute care behavioral health hospital. The role conducts prospective, concurrent, and retrospective reviews; maintains case documentation; communicates with payers; manages authorization requirements; and supports denial and appeal coordination in accordance with the hospital's Utilization Management Plan, approved criteria, payer requirements, and applicable regulations. With minimal supervision, the nurse collaborates with physicians and interdisciplinary teams to support appropriate level of care, medical necessity, length-of-stay management, timely transitions of care, optimal reimbursement, and quality improvement.

Requirements

• Graduate of an accredited nursing program.
• Active, unrestricted Registered Nurse (RN) license in the State of Texas.
• Five to eight years of clinical experience in an inpatient psychiatric setting.
• Knowledge of clinical criteria, managed care requirements, inpatient authorization processes, medical necessity review, denial management, appeal workflows, and behavioral health reimbursement requirements.
• Working knowledge of The Joint Commission patient rights standards and applicable laws and regulations governing mental health care facilities, patient rights, utilization review, and reimbursement.
• Ability to work with child, adolescent, and adult behavioral health populations, demonstrated through education, training, or work experience.
• Strong organizational, prioritization, documentation, follow-through, and data evaluation skills, including the ability to manage multiple payer deadlines and competing priorities.
• Strong interpersonal, communication, assessment, advocacy, and collaboration skills, including the ability to remain calm and poised when working with varied stakeholders.
• Ability to contribute to hospital goals, department objectives, regulatory compliance, quality improvement, and optimal reimbursement.
• Basic computer skills and ability to use electronic medical record systems, payer portals, telephonic review processes, and department tracking tools.
• Ability to identify professional growth needs and seek appropriate development opportunities.
• General good health and stress-coping ability.
• Ability to speak and hear to participate in discussions with healthcare team members, patients, families, and payers.
• Near vision acuity to read computer screens and patient-record documentation accurately.

Nice To Haves

• Previous inpatient psychiatric experience focused on pediatric behavioral health.
• Acute inpatient psychiatric nursing experience.
• Prior experience with pediatric and adult behavioral health utilization review, managed care authorization, denial management, appeal coordination, electronic medical record systems, and utilization management documentation workflows.

Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews for inpatient behavioral health services using hospital-approved medical necessity criteria and payer requirements.
• Complete pre-certification, admission authorization, re-certification, and retrospective reviews within departmental and payer time frames.
• Maintain timely and accurate utilization review documentation in the electronic medical record, payer portals, and departmental tracking systems.
• Communicate with physicians, physician advisors, mental health professionals, interdisciplinary treatment teams, discharge planning staff, outside agencies, managed care organizations, external reviewers, and other payers about clinical information, authorizations, and coverage barriers.
• Participate in treatment team discussions concerning medical necessity, authorization, payer documentation, and level-of-care requirements for child, adolescent, and adult behavioral health populations.
• Identify cases that may not meet medical necessity, continued-stay, or level-of-care criteria and escalate them for timely review and determination.
• Identify complex payer, authorization, or discharge barriers and refer cases to case management, discharge planning, or other appropriate resources.
• Identify and communicate documentation gaps that may affect medical necessity determinations, authorization, regulatory compliance, or reimbursement.
• Document and communicate authorization outcomes, avoidable days, payer barriers, denials, and other utilization indicators.
• Support denial and appeal activities by communicating payer determinations, compiling clinical information, facilitating peer-to-peer reviews, and completing assigned reviews and appeals.
• Communicate relevant clinical information to managed care organizations, external reviewers, and other payers.
• Report potential quality-of-care concerns, patient rights concerns, or regulatory issues to the supervisor or appropriate leadership.
• Maintain current knowledge of The Joint Commission, CMS, and federal, state, local, and payer requirements affecting behavioral health utilization review, patient rights, reimbursement, and regulatory compliance.
• Participate in department meetings, daily huddles, education, quality improvement activities, and assigned projects.
• Perform other appropriate behavioral health utilization management duties as assigned.

Benefits

• PPO medical plan, available day one at no cost for full-time employee-only coverage.
• 100% coverage for preventive healthcare with no copay.
• Paid Time Off available day one.
• Retirement programs through the Teacher Retirement System of Texas (TRS).
• Paid Parental Leave Benefit.
• Wellness programs.
• Tuition reimbursement.
• Public Service Loan Forgiveness (PSLF) Qualified Employer.
• Competitive benefits package including healthcare, PTO, paid holidays, and on-site childcare.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed