Therapy Analyst

TX-HHSC-DSHS-DFPS • Austin, TX

53d

About The Position

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage.

The Registered Therapist V, Managed Care Therapy Analyst, is a senior level position that reports to an Acute Care Utilization Review (ACUR) Unit’s Managed Care Clinical Review Manager. This employee will ensure Texas Medicaid recipients have appropriate access and coordination of medically necessary services through contracted managed care organizations (MCOs) in the STAR, STAR+PLUS, STAR Kids, and STAR Health programs. This position will establish a process to oversee Medicaid managed care organizations (MCOs) efficacy of prior authorization (PA) and utilization review (UR) processes to reduce unnecessary and inappropriate occupational, physical and speech therapy services, Applied Behavioral Analysis services, and Durable Medical Equipment. This position will also safeguard against access to care disparities by ensuring Medicaid MCOs are not underutilizing acute care services by denying necessary and appropriate services. This position will serve as a subject matter expert to other departments within Health and Human Services Commission regarding therapy services.

Requirements

• Master's degree in speech-language pathology required.
• Minimum 10 years experience in a clinical setting required.
• Experience with at least one of the following: Texas Medicaid, managed care, utilization review experience in authorization of clinical services, or case management.
• Knowledge of Texas Medicaid policy related to skilled therapy benefits.
• Experience with therapy PA/authorization and utilization management; therapy practice guidelines; therapy quality assessment, assurance, or improvement; therapy research.
• Knowledge of HHSC programs including Medicaid/CHIP and managed care.
• Familiarity with ICD-10 and HCPCS/CPT codes.
• Excellent computer skills, including Microsoft Office suite.
• Ability to work independently and function effectively as a member of a team, and under tight deadlines with high volume.
• Must possess a current Texas Speech Language Pathology license.

Responsibilities

• Reviews and analyzes, Medicaid MCO policies and procedures, utilization review and clinical documentation.
• Oversee the MCOs prior authorization criteria to determine medical necessity is consistent with amount, duration and scope in the Texas Medicaid Provider Procedures Manual and its appropriate application.
• Review each PA request submitted to ACUR to ensure the MCO consistently identified critical elements in the clinical documentation from the provider to establish medical necessity.
• Evaluate inconsistency and inaccuracy in utilization review to recommend any findings for process improvement.
• Provides constructive and concise summary input regarding utilization management in discussions of case, policy and procedure reviews with MCO leadership and staff during reviews.
• Plan and prepare for the review of identified cases in coordination with the (therapy) Clinical Review Manager.
• Review the identified cases utilizing the ACUR Tools.
• Identify and discuss any errors or discrepancies in MCO systems and steps of prior authorization as evidenced in the documentation submitted by MCO.
• Conducts interviews as needed with utilization management staff members as applicable to overseeing the Utilization management process during reviews.
• Assists in preparing and disseminating post-review follow-up findings and monitoring MCO activities related to non-compliance with utilization management.
• Compile the findings/observations and assist in completing the talking points that will be disseminated to the respective MCOs.
• Assist in developing and administering input related to the rebuttal, reconsideration processes and Corrective Action Plans (CAPs) submitted by the MCO for approval.
• Administers ACUR clinical and UM review tools competently to ensure accurate and consistent documentation of review findings which includes the review of medical necessity for the deliverance of the requested services.
• Complete the respective tools, at various stages of a biennial, readiness or targeted review to conduct analysis.
• Develops and provides clinical review of complaints and inquiries, and technical assistance to MCOs and Independent Review Organizations by analysis of clinical documentation.
• Prepares written report of findings.
• Interprets complex state and federal laws, regulations, and rules related to Texas Medicaid Managed Care in the process of review and provide subject matter expert input for proposed regulatory changes.
• Provides consultation through evaluation and analysis as a specialty area subject matter expert for the various activities to include: contract procurement activities throughout the life-cycle of Texas Medicaid managed care contracts; training and guidance to internal and external staff, informs and collaborates with internal divisions regarding outcomes.
• Other duties as assigned.

Benefits

• comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees
• defined benefit pension plan
• generous time off benefits
• numerous opportunities for career advancement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees