QA/UM Specialist - 1815

CENTRAL COUNTIES CENTER FOR MENTAL•Temple, TX

2d•Onsite

About The Position

Performs complex (journey-level) quality assurance work. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Serves as Utilization Reviewer by supporting the Utilization Manager through reporting activities, utilization data analysis, assisting in the development and implementation of the Utilization Management (UM) Plan, and monitoring agency adherence to Texas Resilience and Recover (TRR) Utilization Management Guidelines and regulatory requirements. Conducts prospective, concurrent, and retrospective chart and utilization reviews to ensure compliance with TRR, Medicaid, TAC, HHSC Performance Contract, and agency standards. Reviews clinical records, ANSA/CANS assessments, level-of-care determinations, service authorizations, discharge planning, continuity of care, and medical necessity documentation to ensure services align with assessed needs and recovery planning. Collects, verifies, analyzes, and reports utilization and performance data; identifies trends, deficiencies, adverse findings, and potential compliance concerns. Supports quality assurance and utilization management activities through case reviews, fidelity reviews, corrective action planning, service improvement initiatives, and monitoring of behavioral health program utilization patterns. Prepares review findings, communicates determinations to staff, and provides consultation regarding documentation standards, TRR requirements, and compliance expectations. Assists in the development and implementation of quality assurance processes, utilization management plans, review tools, policies, procedures, and staff training activities. Coordinates and organizes review assignments and documentation requests; participates in regional meetings, treatment team meetings, and other review-related activities as assigned. Utilizes electronic systems including myAvatar, CMBHS, CARE, MBOW, and Microsoft Office applications to conduct data review, reporting, and documentation activities. May participate in training and development of employees. May become certified instructor for Center required trainings. Performs related duties as assigned.

Requirements

Bachelor’s degree in counseling, social work, psychology, or a related behavioral health field required.
Three (3) years of experience in behavioral health, intellectual and developmental disabilities or chemical dependency.
Valid Texas driver’s license with an acceptable driving record required.
Knowledge of behavioral health service delivery systems, TRR requirements, Medicaid and HHSC regulations, quality assurance practices, utilization management, and medical necessity standards preferred.
Knowledge of ANSA/CANS assessments, level-of-care determination processes, and behavioral health documentation requirements preferred.
Ability to review and analyze clinical documentation, utilization data, and case records for compliance, accuracy, and service alignment.
Ability to identify trends, prepare reports, recommend process improvements, and support corrective action activities.
Ability to interpret and apply state and federal regulations, policies, procedures, and quality standards.
Ability to communicate effectively with staff, leadership, providers, and regulatory entities.
Ability to manage multiple assignments, meet deadlines, and work effectively in a fast-paced environment.
Proficiency with electronic health records, data systems, Microsoft Word, Excel, and other computer applications.
Knowledge of trauma-informed and culturally sensitive service practices.
Use a computer, telephone, and standard office equipment for prolonged periods.
Perform repetitive tasks such as typing, filing, and data entry.
Lift and/or move up to 15 pounds.
Work in an environment with frequent interruptions and changing priorities.
Perform the essential functions of the position, with or without reasonable accommodation, in accordance with the Americans with Disabilities Act (ADA).
Sit, stand, and walk for extended periods of time.
See, hear, and communicate effectively to perform job duties.
Interact frequently with consumers, staff, and the public in a professional and customer focused manner.
Respond appropriately to challenging or unpredictable situations, including safely de-escalating and managing interactions with individuals who may exhibit verbally or physically escalated behavior, in accordance with training and Center policies.
Maintain sufficient mental and emotional health to meet the inherent stressors of the position.
An employee is “mentally fit” when their mental state allows them to perform the essential job duties of their job safely and effectively, which includes being able to concentrate, make decisions, manage stress and maintain focus.

Responsibilities

Serves as Utilization Reviewer by supporting the Utilization Manager through reporting activities, utilization data analysis, assisting in the development and implementation of the Utilization Management (UM) Plan, and monitoring agency adherence to Texas Resilience and Recover (TRR) Utilization Management Guidelines and regulatory requirements.
Conducts prospective, concurrent, and retrospective chart and utilization reviews to ensure compliance with TRR, Medicaid, TAC, HHSC Performance Contract, and agency standards.
Reviews clinical records, ANSA/CANS assessments, level-of-care determinations, service authorizations, discharge planning, continuity of care, and medical necessity documentation to ensure services align with assessed needs and recovery planning.
Collects, verifies, analyzes, and reports utilization and performance data; identifies trends, deficiencies, adverse findings, and potential compliance concerns.
Supports quality assurance and utilization management activities through case reviews, fidelity reviews, corrective action planning, service improvement initiatives, and monitoring of behavioral health program utilization patterns.
Prepares review findings, communicates determinations to staff, and provides consultation regarding documentation standards, TRR requirements, and compliance expectations.
Assists in the development and implementation of quality assurance processes, utilization management plans, review tools, policies, procedures, and staff training activities.
Coordinates and organizes review assignments and documentation requests; participates in regional meetings, treatment team meetings, and other review-related activities as assigned.
Utilizes electronic systems including myAvatar, CMBHS, CARE, MBOW, and Microsoft Office applications to conduct data review, reporting, and documentation activities.
May participate in training and development of employees.
May become certified instructor for Center required trainings.
Performs related duties as assigned.