Job/Position DescriptionTelework is available for this position. The work location is flexible and is not limited to the cities listed in the posting.This position reports to the Acute Care Utilization Review Manager in the Office of the Medical Director, Medicaid and CHIP Services Department. The Behavioral Health Analyst (Program Specialist VI) performs complex behavioral health managed care utilization review oversight and consultation related to the prior authorization (PA) and authorization of behavioral health services within Texas Medicaid. The position leads the MCO oversight activities and includes analysis of Medicaid Managed Care Organizations (MCO) behavioral health-related PA and authorization policies, procedures and protocols to determine risk of MCO over/under utilization of services. This analyst must understand utilization management and be familiar with evidenced based guidelines such as InterQual or MCG (Milliman) criteria for the determination of medical necessity. The Behavioral Health Analyst must have strong research skills for clinical practice and health care delivery and effectively synthesize findings for a clinical and political audience to determine appropriateness of MCO utilization management activities. Must be proactive in seeking input from other staff in the Medicaid/CHIP Division and demonstrate the ability to work as an effective team member with other divisions within HHSC. Participates in, and at times, leads committees, work groups or activities as requested. The analyst in this role provides expert consultation to staff, other agencies, and external persons such as legislators and MCOs that provide utilization management of behavioral health services. The analyst stays abreast of current national standards and requirements affecting the behavioral health aspects of the Texas Medicaid medical benefits.Essential Job Functions(20%) Plans, develops, and implements PA/authorization and utilization management analysis and reporting activities for assigned services. Interprets complex state and federal laws, regulations, and rules related to the program. Develops, reviews and revises internal utilization review program protocols, policies, and tools/techniques for conducting reviews of Medicaid MCOs to ensure that the organizations are using prior authorization and utilization review processes appropriately.(20%) Reviews medical records, MCO policies, and PA/authorization criteria to determine the compliance of approvals/denials of services with PA/authorization policies and procedures and evidence-based standards of care.(20%) Makes recommendations for improvement in the form of written reports as a result of the review analysis. Prepares project updates, summaries, reports, or other documents and keeps management informed on pertinent issues.(10%) Assists in the review and referral of complaints concerning denial of services and inappropriate PA/authorization criteria.(10%) Participates in internal quality improvement activities through reviewing documentation, assisting in development of quality measures, and development of internal protocol.(15%) Provides consultation, training and technical assistance to agency staff, MCO staff, and external stakeholders on behavioral health-related utilization review topics. Informs and collaborates with internal divisions regarding program outcomes. Serves as a clinical subject matter expert in the development and review of utilization management policy. Leads or participates in workgroups and https://jobshrportal.hhsc.state.tx.us/ENG/CareerPortal/job_profile.cfm?szOrderID=604155 Copy the URL in the preceding sentence to an Internet Explorer browser to apply to the job directly through the Texas Health and Human Services Career Portal.