Behavioral Health Utilization Management Nurse

Medix is helping hire a growing Health Plan in need of Behavioral Health UM RN's to assist their team. Candidates MUST have Behavioral Health UM experience at a Health Plan to be considered for the position. Position is FULLY REMOTE. The schedule will be Monday - Friday with some weekend work. Must be comfortable working in CST.

Role is a contract with the potential to move perm! We can consider consider RN's outside of Texas as long as they have a compact license.

Equipment:

• Equipment will NOT be provided. Candidates must have a working laptop or hard drive, with a second screen/monitor, and headset.

Job Duties:

• Review telephonic and faxed clinical information to authorize medically necessary inpatient and outpatient care, utilizing nationally recognized evidenced based clinical criteria or approved medical guidelines. Refers cases that do not meet criteria to Medical Director for review.
• Assists in discharge planning for members who are in psychiatric levels of care and provide appeals standards for denials. Review any requests for extension of these services and if not meeting criteria, refer to the Medical Director.
• Participates in Community Rounds if applicable with Medical Director and coordinating with the Complex Case Management Team for post discharge referrals. Assists co-workers with difficult cases through open discussion. Communicates concerns that arise in these discussions to the Manager and/or Medical Director.
• Maintains knowledge of the designated referral and provider software systems.
• Verifies member eligibility, benefit coverage and facility contract status prior to processing authorization requests.
• Comply with established referral, pre-certification and authorization policies, procedures and processes by related medical affairs for BH.
• Accurately enters the required information into the managed care platform, adhering to BH UM and Appeals policies and procedures.
• Assists in the coordination of care of hospitalized members, medically complex members and members with special needs if applicable.
• Makes appropriate referrals and follow up to other Community programs/departments
• Meets required performance metrics for cases reviewed within established turnaround times. Meets established quality standards.
• Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including, specific departmental process improvement plans.

3-5 Must Have Skills/Qualifications

• RN, current Texas License or current in a National Licensure (Compact participating state).
• Behavioral Health UM experience
• Health Plan experience.

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