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Texas Health and Human Services · 3 weeks ago

Therapy Analyst

Austin, TX

Full-time

Hybrid

Senior Level, Lead/Staff

$7,015.16/mo - $9,439.83/mo

10+ years exp

Texas Health and Human Services Commission (HHSC) is committed to creating a positive impact in the lives of fellow Texans. The Registered Therapist V, Managed Care Therapy Analyst, ensures appropriate access and coordination of medically necessary services for Texas Medicaid recipients through managed care organizations, while also overseeing utilization review processes and providing subject matter expertise on therapy services.

Health Care

No H1B

Responsibilities

Reviews and analyzes, Medicaid MCO policies and procedures, utilization review and clinical documentation

The Registered Therapist V will review the information requested by Acute Care Utilization Review from each MCO to determine if the MCOs policies and procedures are in compliance with the Uniform Managed Care Manual and Uniform Managed Care Contract by completing internal audit tools

This employee will oversee the MCOs prior authorization criteria to determine medical necessity is consistent with amount, duration and scope in the Texas Medicaid Provider Procedures Manual and its appropriate application

The Registered Therapist V, using clinical expertise, will review each PA request submitted to ACUR to ensure the MCO consistently identified critical elements in the clinical documentation from the provider to establish medical necessity

The Registered Therapist V will analyze if MCOs clinical reviewer appropriately considered the assessment record and plan of care (including but not limited to standardized assessment, functional goals, response to therapy, ABA, custom manual/power wheelchairs) to determine amount and duration by applying the medical necessity as per TMPPM, and other governmental codes and contracts

The Registered Therapist V will evaluate inconsistency and inaccuracy in utilization review to recommend any findings for process improvement

Provides constructive and concise summary input regarding utilization management in discussions of case, policy and procedure reviews with MCO leadership and staff during reviews

The Registered Therapist V will plan and prepare for the review of identified cases in coordination with the (therapy) Clinical Review Manager

The Registered Therapist V will then review the identified cases utilizing the ACUR Tools

The Registered Therapist V will identify and discuss any errors or discrepancies in MCO systems and steps of prior authorization as evidenced in the documentation submitted by MCO

Conducts interviews as needed with utilization management staff members as applicable to overseeing the Utilization management process during reviews

Assists in preparing and disseminating post-review follow-up findings and monitoring MCO activities related to non-compliance with utilization management

Under the direction of the (therapy) Clinical Review Manager, the Registered Therapist V will compile the findings/observations and assist in completing the talking points that will be disseminated to the respective MCOs

The Registered Therapist V will assist in developing and administering input related to the rebuttal, reconsideration processes and Corrective Action Plans (CAPs) submitted by the MCO for approval

Administers ACUR clinical and UM review tools competently to ensure accurate and consistent documentation of review findings which includes the review of medical necessity for the deliverance of the requested services

The Registered Therapist V will complete the respective tools, at various stages of a biennial, readiness or targeted review to conduct analysis

Develops and provides clinical review of complaints and inquiries, and technical assistance to MCOs and Independent Review Organizations by analysis of clinical documentation

Prepares written report of findings

The Therapist will receive the complaint from the Quality Assurance team within UR

The Registered Therapist V will review the submitted clinical information to assess the appropriateness of the MCOs determination by evaluating the documentation against the TMPPM, and the MCO’s internal policies and procedures

The Therapist will confer with HHSC’s Assistant Medical Director or Medical Director if needed

Interprets complex state and federal laws, regulations, and rules related to Texas Medicaid Managed Care in the process of review and provide subject matter expert input for proposed regulatory changes

The Therapist will review, analyze and interpret state and federal laws including but not limiting to TMPPM, UMCM, UMCC, Code of Federal Regulations, Texas Insurance Code, Texas Administrative Code

Provides consultation through evaluation and analysis as a specialty area subject matter expert for the various activities to include: contract procurement activities throughout the life-cycle of Texas Medicaid managed care contracts; training and guidance to internal and external staff, informs and collaborates with internal divisions regarding outcomes

The Therapist will review and analyze documents related to Requests for Procurement, clinical policies, as needed

The Therapist will write notifications for providers in collaboration with other departments of HHSC if needed, regarding clarification of clinical policies

The Therapist will lead and participate in provider, inter- and intra- departmental trainings, as needed

Other duties as assigned

Qualification

Texas Speech Language Pathology licenseMedicaid managed care experienceUtilization review experienceICD-10 familiarityMicrosoft Office skillsTeam collaborationIndependent workTime management

Required

Must possess a current Texas Speech Language Pathology license

Master's degree in speech-language pathology required

Minimum 10 Years Experience In a Clinical Setting Required

Experience with at least one of the following: Texas Medicaid, managed care, utilization review experience in authorization of clinical services, or case management

Knowledge of Texas Medicaid policy related to skilled therapy benefits

Experience with therapy PA/authorization and utilization management; therapy practice guidelines; therapy quality assessment, assurance, or improvement; therapy research

Knowledge of HHSC programs including Medicaid/CHIP and managed care

Familiarity with ICD-10 and HCPCS/CPT codes

Excellent computer skills, including Microsoft Office suite

Ability to work independently and function effectively as a member of a team, and under tight deadlines with high volume