Job Description

Job Description

About Us

Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.

Our Core Values are:

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• We serve faithfully by doing what's right with a joyful heart.
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• We never settle by constantly striving for better.
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• We are in it together by supporting one another and those we serve.
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• We make an impact by taking initiative and delivering exceptional experience.
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Benefits

Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:

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• Eligibility on day 1 for all benefits
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• Dollar-for-dollar 401(k) match, up to 5%
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• Debt-free tuition assistance, offering access to many no-cost and low-cost degrees, certificates and more
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• Immediate access to time off benefits
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At Baylor Scott & White Health, your well-being is our top priority.

Note: Benefits may vary based on position type and/or level

Job Summary

Utilization Review Specialist conducts reviews and shares knowledge with healthcare staff. Works closely with Medical Director and Health Services leadership. Manages utilization and formulates policies. The role is integral in navigating healthcare challenges and improving care quality.

Essential Functions of the Role

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• Process all Behavioral Health and Substance Use Disorder authorizations within the designated turnaround times specified for all lines of business.
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• Make accurate approval verdicts based on clinical information. Follow medical criteria and discuss with the Medical Director. Notify providers and members promptly.
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• Request medical records for necessity. Consult with providers for clarity.
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• Inspect all likely denials and refer any medical necessity denials and out-of-network requests to the Medical Director for final decision-making.
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• Compile clear and accurate denial explanations that precisely reflect the clinical state and reasons why certain services gained no approval.
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• Advise therapy providers on authorization. Provide speech, physical, and occupational therapy services. Reach out to providers deviating from guidelines.
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• Assist with network management and ensure members are using in-network providers wherever possible.
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• Identify at-risk members. Refer to management programs, community services, and agencies. Report member abuse or exploitation following laws and company policy.
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• Participate in quality initiatives, including case reviews, claims reviews and studies, testing for interrater reliability, audits, and continuous process improvement.
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• Team up with internal and external clinical staff and management to provide services to members.
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• Keep updated on approved utilization management criteria, guidelines, and regulations.
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Key Success Factors

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  Experience working with Substance use treatment experience and/or behavioral health treatment 

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  Experience with Utilization Management for Substance use treatment experience and/or behavioral health treatment in managed care setting

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  Experience working at a health plan

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  Proven ability to work effectively within a fast paced, changing environment

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  Proven computer and typing proficiency to enter/retrieve data in electronic clinical records and provide customer service on the phone 

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• Quickly adapting to software applications is crucial in this role. Proficient operation is necessary for success.
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Belonging Statement

We believe that all people should feel welcomed, valued and supported, and that our workforce should be reflective of the communities we serve.

Qualifications

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• Bachelor's degree
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• At least (3) three years of related professional experience
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• Must have: LCSW 
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• Hybrid expectation- occasional on-site as business demands
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