Utilization Management & Case Review Specialist

Texas Family Care Network•Dallas, TX

About The Position

The Utilization Management & Case Review Specialist conducts utilization reviews, internal case record reviews, and quality assessments to support compliance, service quality, and positive outcomes. The specialist analyzes service utilization patterns, reviews documentation for accuracy and compliance, identifies trends and risk areas, and collaborates with internal teams and providers to promote continuous quality improvement. The role contributes to monitoring service effectiveness, ensuring contractual and regulatory compliance with case management paperwork, and supporting improvement initiatives through data-informed recommendations and case review findings. The specialist works with internal teams and programs to streamline utilization review processes, communicates and schedules as needed, and receives ongoing supervision from a supervisor regarding program matters. The position operates during traditional office hours, with flexibility to meet department and employee or program needs.

Requirements

Bachelor’s degree in Healthcare Administration, Social Work, Human Services, Business Administration, Public Administration, Information Systems, or a related field.
Valid driver’s license and auto insurance.
Three years of professional experience in quality assurance, utilization management, compliance, auditing, case review, provider performance, healthcare, behavioral health, child welfare, managed care, or a related field.
Required clearances: DPS, DFPS, FBI, CBCU Eligibility Determination, and child abuse clearances.

Nice To Haves

One year of experience with the Texas child welfare system, including DFPS, a Child Placing Agency, a General Residential Operation/Residential Treatment Center, or a Single Source Continuum Contractor.

Responsibilities

Conduct utilization reviews to assess the appropriateness, necessity, frequency, and duration of services based on the identified service package.
Monitor service utilization trends and identify potential overutilization, underutilization, or service gaps.
Evaluate cases for alignment with contractual requirements, organizational policies, and established guidelines.
Identify trends requiring further investigation or intervention.
Assist with implementing the Utilization Management Plan.
Assist with developing policies and procedures related to utilization management and case review processes.
Assess adherence to established service standards, policies, and procedures.
Apply standardized review tools and scoring methodologies, and participate in calibration activities to maintain inter-rater reliability.
Identify findings, deficiencies, trends, and risk areas through case reviews and utilization monitoring.
Develop review summaries and corrective action recommendations, and monitor follow-up activities related to quality improvement initiatives and corrective action plans.
Support preparation for external audits, accreditation reviews, and monitoring activities.
Assist in evaluating provider performance against established quality and performance indicators.
Collaborate with the Data Outcome team to communicate findings and improvement opportunities.
Participate in provider education and performance improvement initiatives when needed.
Track authorization and utilization metrics and prepare reports for leadership review.
Perform internal case record reviews and documentation audits.
Evaluate case management documentation for completeness, accuracy, timeliness, and compliance with regulatory and contractual requirements.
Maintain accurate records of review findings and completed quality assurance activities.
Communicate with internal teams and programs to streamline utilization review processes; assist with communication and scheduling.
Communicate with the supervisor on an ongoing basis throughout the week about program matters by phone, email, written message, and, when possible, in person.