PRN Utilization Review Coordinator

The Menninger Clinic; Houston (TX); On-site; USD 55,000 - 83,000; Full time

Job summary

The Menninger Clinic in Houston, TX seeks a PRN Utilization Management professional to support daily operations with insurance reviews and documentation. You will collaborate with treatment teams, coordinate certifications, and ensure proper authorization workflows as part of discharge planning.

Requires a Master’s degree in a clinical field and licensure (LPC/LMSW/RN/LCSW) with 3+ years in healthcare and at least 1 year in insurance reviews.

Qualifications

• Master’s degree and licensure in a clinical discipline or equivalent UR experience.
• Licenses: LPC, LMSW, RN, or LCSW.
• Three years’ health care experience; at least one year in insurance reviews.
• Proficient with computers, calculators, phones, fax machines and copiers.
• Basic knowledge of Microsoft Office and health insurance regulations; DSM IV-TR knowledge.

Responsibilities

• Perform internal and external record reviews for daily department operations.
• Cooperate with Admissions to complete certifications and document outcomes.
• Conduct concurrent utilization reviews with payers and document results.
• Obtain and communicate authorizations for services not covered under per diems.
• Maintain ethical and thorough charting across reviews.
• Assist in surveys for regulatory agencies and payers.

Skills

Insurance reviews

Utilization management

Team collaboration

Documentation

Regulatory awareness

Education

Master's degree in clinical field

Tools

Microsoft Office

Job description

This position is PRN/as-needed only. Shifts needing coverage will be Monday - Friday 8:00am to 5:00pm.

Key Functions

1. Perform both internal and external record reviews as part of daily department operations.

• Cooperates with Admissions to complete certifications as needed and documents outcome in certification record.
• Performs concurrent utilization review with insurance companies and relevant payers, documenting outcome of same in the certification record.
• Obtains and documents authorization for services not covered under per diems and communicates directly to physicians/clinician.
• Maintains an appropriate and ethical performance of reviews, both internal and external.

2. Develop and maintain professional relationships with treatment team members to enhance the role of Utilization Management within the organization.

• Communicates to appropriate members of the treatment team the status of the cases assigned with mandatory reporting to the physician or team designee.
• Communicates need for Peer Reviews between physician and payers, facilitating as needed; completes documentation.
• Attends team/staff meetings per program scheduling, as clinically indicated.
• Educates teams and patients as needed regarding benefits as they relate to discharge options and utilizing our continuum of care.

3. Assist in preparedness for surveys by regulatory agencies and payers.

4. Audits/reviews charts-depth and intensity to be determined by data collection reports. Communicates charting deficits to the team prior to completing reviews. Ensures all review information is in the chart prior to completion of review.

Education: Required

Master’s degree and licensure in a clinical discipline, (i.e. Social Work, Psychology, Nursing, or healthcare field.) Equivalent years of specific UR experience may be substituted for licensure.

License/Certification:

LPC, LMSW, RN, LCSW

Experience:

• Three years’ experience in a health care field.
• Minimum of one-year full-time experience performing insurance reviews, either pre-certification and/or concurrent reviews.
• Proficient in the use of computers, calculators, phones, fax machines, and copy machines.
• Basic knowledge of Microsoft Office, health insurance/collection regulations, team concepts/performance improvement, human behavior and psychopathology. Basic knowledge of managed care concepts, social/family systems, and treatment modalities.
• Knowledge of DSM IV-TR