We’re hunting for a Utilization Management Social Worker, someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will provide prior authorization of outpatient and inpatient behavioral health services requiring authorization. This process includes using clinical judgement for utilization management, application of product benefits, understanding of regulatory requirements, and verification of medical necessity utilizing evidence-based criteria. In addition, provider education is a component of this process.
Think you’ve got what it takes?
Job Duties & Responsibilities
- Assess the treatment plan, clinical information, and medical necessity of all requested services.
- Utilizes established criteria to appropriately certify requested services within established timeframe required.
- Consults with physicians and therapists regarding member’s history and current care needs on an ongoing basis.
- Refers cases failing to meet medical necessity criteria to the medical director or designee for review and disposition.
- Conducts timely entry of information into systems and assigns appropriate length of service per established guidelines and communicates authorization numbers to providers and members.
- Evaluates benefit coverage and regulatory guidelines pertinent to decision making.
- Facilitates provider communication and education.
- Liaisons with internal and external managed care staff members.
- Assess and refers potential case management cases.
- Ongoing assessment for quality indicators and concerns.
Skills & Requirements
- Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees unless approved for a medical or religious exemption.
- Required master's degree in social work
- Required Licenses/Certifications
- LMSW - Licensed Master Social Worker by the Texas Behavioral Health Ex Counc (TBHEC)
- LCSW - Lic Clinical Social Worker by the Texas Behavioral Health Ex Counc (TBHEC)
- LMSW-AP - Lic Mas Soc Wkr - Adv Pract by the Texas Behavioral Health Ex Counc (TBHEC)
- Required 3 years Behavioral Health clinical experience and 2 years of Managed Care Experience
- Preferred 2 years of utilization management
About Texas Children’s
Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.
To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.
Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.