Utilization Management Clinician - Behavioral Health - PCHP Hybrid

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family.  PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area.  PCHP works to fulfill of our mission by empowering members to live healthier lives.  By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job—it’s a passion to serve and improve lives every day.

**Anticipated start date: July 2025**

Primary Purpose:

Parkland Community Health Plan’s (PCHP’s) Utilization Management (UM) Clinician is responsible for processing authorization requests for members requiring physical and/or behavioral healthcare for outpatient and inpatient service. UM responsibilities include but are not limited to processing of prior and concurrent review authorizations, discharge planning and transitions of care. Oversees the application of clinical guidelines in determining appropriateness of requested and continued healthcare services. Ensures that all clinical decisions are completed according to evidence based best practice guidelines and meets regulatory requirements. Seeks Medical Director review of cases not meeting criteria and monitors time frames for decision making and notifications of decision.

Why Parkland Health?

At Parkland Health, we believe that our success is built on the dedication, passion, and unique perspectives of our team members. When you join us, you're not just starting a job – you're beginning a meaningful career that supports your personal growth and professional aspirations. We are committed to fostering a workplace where every individual is encouraged to reach their full potential. At Parkland, you'll have the opportunity to work alongside passionate professionals in nationally recognized specialty areas, and be part of a culture that supports learning, collaboration, and innovation. Our team members don’t just work here—they thrive here, making a lasting impact on the health and well-being of the communities we serve. Join us, and see why your career matters here!

Inside the Parkland Culture

Benefits:

• Medical - Active Day 1 of hire
• Dental
• Vision
• Life Insurance
• Disability Insurance
• Mandatory Savings Plan
• Flexible Spending Accounts
• Paid Personal Leave
• Tuition Reimbursement
• Employee Health Center
• And more!

Job Summary:

Care Coordination and Clinical Review -

• Performs clinical utilization reviews of pre-authorization, concurrent and retrospective requests per clinical information submitted by providers using clinical criteria for medical necessity and appropriateness of care. Approves services or forwards requests to the appropriate medical director for further review, as appropriate.
• Performs utilization management functions competently and adheres to the guidelines for authorization turn-around times.
• Reviews clinical service requests from members or providers using evidence based clinical guidelines, analyzes clinical information, and correctly applies clinical criteria.
• Requests additional information from members or providers in a timely manner and makes referrals to other clinical programs as needed.
• Identifies members that are high risk or who have conditions that may need service coordination or disease management and facilitates appropriate referrals.
• Works collaboratively with provider network and health services team to coordinate member care.
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
• Answers utilization management directed telephone calls, managing them in a professional and competent manner. Conducts ongoing availability, monitoring, and oversight of non-clinical staff activities.
• Uses effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to assure appropriate levels of care are received by members.
• Identifies and utilizes appropriate alternative and non-traditional available resources in managing cases.
• Provides accurate and complete documentation along with an explanation of the rationale that was used to approve requests.
• Documents and maintains clinical information in health management systems ensuring all pertinent information is entered in a timely manner and in accordance with department guidelines.
• Performs medical necessity documentation to expedite approvals and ensure that appropriate follow up is performed.
• Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.
• Proficient computer and Microsoft Office skills. Ability to learn new software programs.
• Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.
• Familiar with InterQual and Texas Medicaid Provider Procedures Manual and utilization guidelines.
• Solid understanding of managed care and medical terminology.
• Knowledge of and competence in use of UM software.

Professional Accountability -

• Promotes and supports a culturally welcoming and inclusive work environment.
• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
• Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely.
• Adheres to hybrid work schedule requirements.
• Attends required meetings and town halls.
• Recognizes and communicates ethical and legal concerns through the established channels of communication.
• Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
• Maintains confidentiality at all times.
• Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.

Minimum Qualifications:

• BSN Degree from and accredited Professional School of Nursing - OR - Master of Social Work (MSW) Degree from an accredited program.
• Three (3) years of acute clinical nursing or medical management experience in clinical social work or behavioral health experience required.
• Three (3) years of experience in Texas Medicaid, Medicaid, or a Medicaid managed care organization or health plan preferred.
• One (1) year experience with the implementation of utilization management policies, procedures, and protocols for physical health and/or behavioral health services and knowledge of utilization management and case management principles is preferred.
• Experience managing pediatric population with complex PH/BH conditions preferred.
• Experience in Texas Medicaid and NCQA is preferred.

Certification/Registration/Licensure

• RNs Only: Current/Valid State of Texas RN license in good standing without any stipulations/stipulations.
• MSWs Only: Current/Valid State of Texas license LPC, LMFT, or LCSW without any stipulations/restrictions.

Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.