Job Description

Position Summary:

The Licensed Clinical Reviewer with Texas Care is responsible for processing authorization requests for clients requiring behavioral healthcare for outpatient MHR services. The responsibilities include but are not limited to processing of prior and concurrent review authorizations, discharge planning and transitions of care. Oversee the application of clinical guidelines in determining appropriateness of requested and continued mental health rehabilitative services. Ensures that all clinical decisions are completed according to evidence based best practice guidelines and meets regulatory requirements.

Job Summary - Licensed Clinical Reviewer:

· Complete comprehensive initial biopsychosocial assessments and assign proper diagnosis.

· Complete reassessments as required by the MCOs.

· Perform clinical reviews, concurrent and retrospective requests per clinical information submitted by providers using clinical criteria for medical necessity and appropriateness of care.

· Approve services or forwards requests to the Clinical Director for further review, as appropriate.

· Review clinical service requests from clients or providers using evidence based clinical guidelines, analyzes clinical information, and correctly applies clinical criteria.

· Request additional information from clients or providers in a timely manner and makes referrals to other clinical programs as needed.

· Conduct reviews of clinical records and assisting with treatment planning to ensure that appropriate levels of care and modalities are being provided

· Provide training & guidance to treatment teams regarding necessary documentation and language for authorizations

· Answer peer reviews, managing them in a professional and competent manner.

· Provide accurate and complete documentation along with an explanation of the rationale that was used to approve requests.

· Document and maintain clinical information in electronic health record ensuring all pertinent information is entered in a timely manner and in accordance with department guidelines.

· Perform medical necessity documentation to expedite approvals and ensure that appropriate follow up is performed.

· Ensure work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.

· Demonstrated proficiency in basic computer skills and typing, i.e., Microsoft Windows, Outlook, Word, PowerPoint, Internet Explorer, etc. Ability to learn new software programs.

· Knowledge of Texas Medicaid; Familiar with Texas Medicaid Provider Procedures Manual and utilization guidelines.

· Solid understanding of managed care and medical terminology.

· Knowledge of and competence in use of electronic health record – Notenetic.

Salary Range: $70,000 - $80,000 USD per year

Professional Accountability:

· Promote and support a culturally welcoming and inclusive work environment.

· Act with the highest integrity and ethical standards while adhering to Texas Care’s Mission, Vision, and Values.

· Adhere to organizational policies, procedures, and guidelines.

· Complete assigned mandatory training

· Adher to hybrid/remote work schedule requirements.

· Attend required meetings

· Recognize and communicate ethical and legal concerns through the established channels of communication.

· Demonstrate accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.

· Maintain confidentiality at all times.

· The ability to work independently with minimal supervision and demonstrate initiative

· Working knowledge of HIPAA Privacy and Security Rules

· Ability to multi-task and assist with team coverage and provide support when needed

· Ability to build relationships both internally and externally

· Additional duties as assigned by leadership; Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies.

Minimum Qualifications:

· Three (3) years of experience in clinical social work or behavioral health experience required.

· Three (3) years of experience in Texas Medicaid, or a Medicaid managed care organization or health plan preferred.

· Master’s degree in social work, psychology, counseling, or a related field (required).

· Ability to work independently and manage a flexible schedule, with minimal direct supervision.

· Must possess NPI number and CAQH number.

· Must initiate credentialing with Texas Medicaid.

· Knowledge: Strong understanding of Texas Health and Human Services (HHS) guidelines, Medicaid billing, and community-based mental health services.

Certification/Licensure:

· Current/Valid State of Texas license LPC, LMFT, or LCSW without any stipulations/restrictions.

Knowledge, Skills, & Abilities:

· Must be able to diagnose individuals according to DSM standards

· Must be able to develop and execute a treatment plan

· Must be able to supervision and instruct non-licensed clinicians appropriately

· Demonstrated knowledge of ICD-10-CM codes, understanding of payer rules and regulations, including Medicare and Medicaid

· Completes and attests to completion of all mandatory training as identified in HHSC and agency’s required training.

· Ability to support the agency's culture, growth, and success through communication, accountability, and positivity

· Ability to think and work independently, while working in an overall team environment

· Effective and professional communication skills, both verbal and written

· Well-organized and adaptable

· Ability to develop and bring together interdisciplinary teams

· Effective conflict resolution skills

· Demonstrates good insight and judgment

· Possesses an engaging and enthusiastic personality

· Competent in using Microsoft Word, Excel, Power Point, Google applications, Go to Meeting, the Internet, and other software applications

· Extreme attention to detail

· Must possess problem solving, critical thinking skills

Additional Requirements

· Proof of valid Texas Driver's License (Type C)

· Three (3) professional employment references

· Cleared criminal background check and signed statement regarding felony indictments/convictions

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