Utilization Review SLP - PCHP

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Hybrid Position, D/FW Area

Primary Purpose: Responsible for reviewing authorization requests for speech therapy treatments, services, or procedures to determine whether they qualify for insurance coverage.

 Minimum Specifications

 Education:

• Master's degree in Speech - Language Pathology required.

 Experience:

• Minimum of two (2) years of combined experience providing speech therapy services in healthcare, home health, inpatient, outpatient, and/or school setting required. Pediatric clinical experience preferred. 
• Minimum of two (2) year of Prior authorization review experience with a health plan or Managed Care Organization is preferred.
• Knowledge of prior authorization/utilization management process and the ability to interpret Texas Medicaid guidelines preferred.

 Equivalent Education and/or Experience:

 Certification/Registration/Licensure:

• Licensed by the Texas State Board of Examiners for Speech Language Pathology and Audiology required.
• Certificate of Clinical Competence (CCC) issued by the American Speech and Hearing Association (ASHA) required

 Required Tests for Placement:

Skills or Special Abilities:

• Must be able to demonstrate a working knowledge of pediatric and/or adult neurogenic language disorders, swallowing, aphasia, dysarthria, apraxia, voice disorders, alaryngeal communication, articulation, and normal language development. 
• Competency in speech therapy prior authorization functions including application of criteria and timelines. 
• Demonstrated ability to analyze clinical information and accurately apply clinical criteria. 
• Knowledge of utilization management and case management principles. 
• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms. 
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization. 
• Excellent analytical and problem-solving skills. 
• Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities. 
• Ability to write clearly and succinctly with a high level of attention to detail.
• 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.

Responsibilities:

• Plan of Care/Clinical Operations Assesses clinical documentation to provide recommendations ensuring members receive medically appropriate services.
• Provides consultation regarding speech therapy medical necessity appeals. Accountable for ensuring requests meet state, national standards, and contractual requirements.
• Serves as a subject matter expert (SME) in the utilization review and authorization of Outpatient/Home Health Speech Therapy services including Durable Medical Equipment (DME) requests consistent with therapy practices.
• Performs clinical reviews of speech therapy prior authorization requests for appropriate care and setting, following guidelines and policies. Approves services or forwards requests to the appropriate medical director along with recommendations for other determinations.
• Performs detailed utilization review of speech therapy service request based on evidenced based practice, documentation standards as indicated by national therapy associations, and organizational policies.
• Refers members to case management as appropriate based on service request assessments.
• Reviews for the medical necessity and appropriateness of Durable Medical Equipment based on policies and clinical guidelines.
• Authorize, direct, and monitor care being provided in speech therapy for medical necessity and appropriateness of care.
• Reviews plans of care to ensure functional outcomes and use of clinical practice guidelines. Provides support for specialty therapy providers, including assistance with clinical education, consultation and guidance on matters related to speech therapy authorization and provision.
• Provides clinical expertise to multi-functional areas within organization to support provide relations and operations.
• Performs prior authorization functions competently and adheres to the guidelines for prior authorization turn-around times.
• Requests additional information from members or providers in timely manner and makes referrals to other clinical programs as needed.
• Identifies members that are high risk or who have conditions that may need case or disease management.

Quality:

•  Integrates health literacy principles into all communication including Members and Providers.
• Supports strategies that meet clinical, quality and network improvement goals.
• Promotes the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.
• For staff in clinical roles, foster collaborative positive relationships with members and/or providers to promote and support evidence-based practices and care coordination.
• Engages in process and performance improvement initiatives, including training and auditing speech therapy request.

 Regulatory:

•  Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.

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.

Parkland Health and Hospital System 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. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.