Behavioral Health Utilization Review Nurse

Texas Behavioral Health Center

The Texas Behavioral Health Center is a newly completed state-funded psychiatric hospital opening in Dallas’ Southwestern Medical District that is owned by the Texas Health and Human Services Commission (HHSC) and operated by UT Southwestern Medical Center.

When fully operational, the 505,000-square-foot facility will house 292 beds – 200 for adult patients and 92 for children and adolescents. As DFW’s first state-funded behavioral health hospital, it is designed to deliver state-of-the-art, patient-centered care in a modern and healing environment. The center provides comprehensive behavioral health treatment and features private patient rooms, abundant access to natural light and nature, and thoughtfully designed spaces that promote recovery. The hospital will also provide training to all behavioral health disciplines.

As employees of UT Southwestern, team members will join a world-class academic medical center committed to patient-centered care, innovation, interdisciplinary collaboration, and preparing patients for successful reintegration into their families and communities. With competitive benefits and a mission-driven culture, Texas Behavioral Health Center offers an unparalleled opportunity to make a lasting impact on mental health care in North Texas. Learn more about Texas Behavioral Health Center here!

WHY UT SOUTHWESTERN?
With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the No. 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career! 

JOB SUMMARY
The Inpatient Behavioral Health Utilization Management Nurse performs utilization management activities for patients receiving services at UT Southwestern's acute care behavioral health hospital. This role conducts prospective, concurrent, and retrospective reviews; maintains case documentation; communicates with payers; manages authorization requirements; and supports denial and appeal coordination in accordance with the hospital's Utilization Management Plan, approved criteria, payer requirements, and applicable regulations. The position collaborates with physicians and interdisciplinary teams to support appropriate level of care, medical necessity, length-of-stay management, timely transitions of care, optimal reimbursement, and quality improvement with minimal supervision. 

 

BENEFITS
UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include\:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer

• Learn more about these and other UTSW employee benefits!

EXPERIENCE AND EDUCATION

Required

• Education
  Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas 
   

• Experience
  Five to eight years of clinical experience in an inpatient psychiatric setting 
   

• Licenses and Certifications
  (RN) REGISTERED NURSE holds an active unrestricted RN license in the State of Texas. 
   

Preferred

• Experience
  Previous experience in an inpatient psychiatric setting with a focus on pediatric behavioral health is highly preferred 
  Acute inpatient psychiatric nursing experience 
  Prior experience with pediatric and adult behavioral health utilization review, managed care authorization, denial management, appeal coordination, electronic medical record systems, and utilization management documentation workflows is highly preferred 
   

JOB DUTIES

• Conducts prospective, concurrent, and retrospective utilization reviews for inpatient behavioral health services using hospital-approved medical necessity criteria and applicable payer requirements to support appropriate level of care, continued stay, discharge readiness, length-of-stay management, and timely transitions of care.
• Completes pre-certification, admission authorization, re-certification, and retrospective reviews for inpatient psychiatric services within established departmental and payer time frames.
• Maintains timely and accurate utilization review documentation in the electronic medical record, payer portals, and departmental tracking systems in accordance with established workflows and payer deadlines.
• Communicates with physicians, physician advisors, mental health professionals, interdisciplinary treatment teams, discharge planning staff, outside agencies, managed care organizations, external reviewers, and other payers to obtain and submit clinical information, provide authorization updates, and address coverage barriers.
• Participates in treatment team discussions to identify and communicate medical necessity, authorization, payer documentation, and level-of-care requirements for child, adolescent, and adult behavioral health populations.
• Identifies cases that do not appear to meet medical necessity, continued stay, or appropriate level-of-care criteria and escalates them to physician advisors, attending physicians, and leadership for timely review and determination.
• Identifies cases with complex payer, authorization, or discharge barriers and refers them to case management, discharge planning, or other appropriate resources.
• Identifies and communicates documentation gaps that may affect medical necessity determinations, authorization, regulatory compliance, or reimbursement while maintaining physician and treatment team accountability for clinical documentation.
• Accurately documents and communicates authorization outcomes, avoidable days, payer barriers, denials, and other assigned utilization indicators to designated resources and leadership.
• Supports denial and appeal activities by communicating payer determinations, compiling relevant clinical information, facilitating peer-to-peer reviews, and completing assigned retrospective reviews and appeals within required time frames.
• Communicates relevant clinical information to managed care organizations, external reviewers, and other payers to support review of medically necessary behavioral health services.
• Identifies and communicates potential quality-of-care concerns, patient rights concerns, or regulatory issues to the Inpatient Behavioral Health Utilization Management Nurse Supervisor or other appropriate leadership in a timely manner.
• Maintains current knowledge of The Joint Commission, CMS, federal, state, local, and payer requirements affecting behavioral health utilization review, patient rights, reimbursement, and regulatory compliance.
• Participates in department meetings, daily huddles, education, quality improvement activities, and assigned projects related to behavioral health utilization management.
• Performs other appropriate behavioral health utilization management duties as assigned.

Knowledge, Skills and Abilities

• Demonstrates knowledge of clinical criteria, managed care requirements, inpatient authorization processes, medical necessity review, denial management, appeal workflows, and reimbursement requirements for behavioral health services.
• Demonstrates working knowledge of The Joint Commission patient rights standards and applicable federal and state laws and regulations governing mental health care facilities, patient rights, utilization review, and reimbursement.
• Ability to work with child, adolescent, and adult behavioral health populations as demonstrated through education, training, or work experience.
• Exceptional organizational, prioritization, documentation, follow-through, and data evaluation skills with the ability to manage multiple payer deadlines, competing priorities, and utilization management trends such as avoidable days, denial patterns, authorization barriers, and documentation gaps.
• Strong interpersonal, communication, assessment, advocacy, and collaboration skills with the ability to remain calm and poised when working with physicians, physician advisors, mental health professionals, nursing leadership, payers, agencies, patients, families, and team members.
• Ability to organize tasks and contribute to hospital goals, department objectives, regulatory compliance, quality improvement, and optimal reimbursement.
• Basic computer skills and ability to use electronic medical record systems, payer portals, telephonic review processes, and department tracking tools.
• Identifies professional growth needs and seeks appropriate development opportunities in behavioral health utilization management, regulatory compliance, payer requirements, and clinical review criteria.
• General good health and stress coping ability.
• Ability to speak and hear, to allow discussions with physicians, patients, families, payers, and other members of the healthcare team.
• Possess near vision acuity for accurate reading of computer screens and documentation in patient records.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Physical Requirements

• Talking

Working Conditions

• Office Setting

Salary Information
Salary is commensurate with education, skills, and relevant experience.

SECURITY AND EEO STATEMENT

Security
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.
 

Texas Behavioral Health Center

The Texas Behavioral Health Center is a newly completed state-funded psychiatric hospital opening in Dallas’ Southwestern Medical District that is owned by the Texas Health and Human Services Commission (HHSC) and operated by UT Southwestern Medical Center.

When fully operational, the 505,000-square-foot facility will house 292 beds – 200 for adult patients and 92 for children and adolescents. As DFW’s first state-funded behavioral health hospital, it is designed to deliver state-of-the-art, patient-centered care in a modern and healing environment. The center provides comprehensive behavioral health treatment and features private patient rooms, abundant access to natural light and nature, and thoughtfully designed spaces that promote recovery. The hospital will also provide training to all behavioral health disciplines.

As employees of UT Southwestern, team members will join a world-class academic medical center committed to patient-centered care, innovation, interdisciplinary collaboration, and preparing patients for successful reintegration into their families and communities. With competitive benefits and a mission-driven culture, Texas Behavioral Health Center offers an unparalleled opportunity to make a lasting impact on mental health care in North Texas. Learn more about Texas Behavioral Health Center here!

WHY UT SOUTHWESTERN?
With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the No. 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career! 

JOB SUMMARY
The Inpatient Behavioral Health Utilization Management Nurse performs utilization management activities for patients receiving services at UT Southwestern's acute care behavioral health hospital. This role conducts prospective, concurrent, and retrospective reviews; maintains case documentation; communicates with payers; manages authorization requirements; and supports denial and appeal coordination in accordance with the hospital's Utilization Management Plan, approved criteria, payer requirements, and applicable regulations. The position collaborates with physicians and interdisciplinary teams to support appropriate level of care, medical necessity, length-of-stay management, timely transitions of care, optimal reimbursement, and quality improvement with minimal supervision. 

 

BENEFITS
UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include\:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer

• Learn more about these and other UTSW employee benefits!

EXPERIENCE AND EDUCATION

Required

• Education
  Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas 
   

• Experience
  Five to eight years of clinical experience in an inpatient psychiatric setting 
   

• Licenses and Certifications
  (RN) REGISTERED NURSE holds an active unrestricted RN license in the State of Texas. 
   

Preferred

• Experience
  Previous experience in an inpatient psychiatric setting with a focus on pediatric behavioral health is highly preferred 
  Acute inpatient psychiatric nursing experience 
  Prior experience with pediatric and adult behavioral health utilization review, managed care authorization, denial management, appeal coordination, electronic medical record systems, and utilization management documentation workflows is highly preferred 
   

JOB DUTIES

• Conducts prospective, concurrent, and retrospective utilization reviews for inpatient behavioral health services using hospital-approved medical necessity criteria and applicable payer requirements to support appropriate level of care, continued stay, discharge readiness, length-of-stay management, and timely transitions of care.
• Completes pre-certification, admission authorization, re-certification, and retrospective reviews for inpatient psychiatric services within established departmental and payer time frames.
• Maintains timely and accurate utilization review documentation in the electronic medical record, payer portals, and departmental tracking systems in accordance with established workflows and payer deadlines.
• Communicates with physicians, physician advisors, mental health professionals, interdisciplinary treatment teams, discharge planning staff, outside agencies, managed care organizations, external reviewers, and other payers to obtain and submit clinical information, provide authorization updates, and address coverage barriers.
• Participates in treatment team discussions to identify and communicate medical necessity, authorization, payer documentation, and level-of-care requirements for child, adolescent, and adult behavioral health populations.
• Identifies cases that do not appear to meet medical necessity, continued stay, or appropriate level-of-care criteria and escalates them to physician advisors, attending physicians, and leadership for timely review and determination.
• Identifies cases with complex payer, authorization, or discharge barriers and refers them to case management, discharge planning, or other appropriate resources.
• Identifies and communicates documentation gaps that may affect medical necessity determinations, authorization, regulatory compliance, or reimbursement while maintaining physician and treatment team accountability for clinical documentation.
• Accurately documents and communicates authorization outcomes, avoidable days, payer barriers, denials, and other assigned utilization indicators to designated resources and leadership.
• Supports denial and appeal activities by communicating payer determinations, compiling relevant clinical information, facilitating peer-to-peer reviews, and completing assigned retrospective reviews and appeals within required time frames.
• Communicates relevant clinical information to managed care organizations, external reviewers, and other payers to support review of medically necessary behavioral health services.
• Identifies and communicates potential quality-of-care concerns, patient rights concerns, or regulatory issues to the Inpatient Behavioral Health Utilization Management Nurse Supervisor or other appropriate leadership in a timely manner.
• Maintains current knowledge of The Joint Commission, CMS, federal, state, local, and payer requirements affecting behavioral health utilization review, patient rights, reimbursement, and regulatory compliance.
• Participates in department meetings, daily huddles, education, quality improvement activities, and assigned projects related to behavioral health utilization management.
• Performs other appropriate behavioral health utilization management duties as assigned.

Knowledge, Skills and Abilities

• Demonstrates knowledge of clinical criteria, managed care requirements, inpatient authorization processes, medical necessity review, denial management, appeal workflows, and reimbursement requirements for behavioral health services.
• Demonstrates working knowledge of The Joint Commission patient rights standards and applicable federal and state laws and regulations governing mental health care facilities, patient rights, utilization review, and reimbursement.
• Ability to work with child, adolescent, and adult behavioral health populations as demonstrated through education, training, or work experience.
• Exceptional organizational, prioritization, documentation, follow-through, and data evaluation skills with the ability to manage multiple payer deadlines, competing priorities, and utilization management trends such as avoidable days, denial patterns, authorization barriers, and documentation gaps.
• Strong interpersonal, communication, assessment, advocacy, and collaboration skills with the ability to remain calm and poised when working with physicians, physician advisors, mental health professionals, nursing leadership, payers, agencies, patients, families, and team members.
• Ability to organize tasks and contribute to hospital goals, department objectives, regulatory compliance, quality improvement, and optimal reimbursement.
• Basic computer skills and ability to use electronic medical record systems, payer portals, telephonic review processes, and department tracking tools.
• Identifies professional growth needs and seeks appropriate development opportunities in behavioral health utilization management, regulatory compliance, payer requirements, and clinical review criteria.
• General good health and stress coping ability.
• Ability to speak and hear, to allow discussions with physicians, patients, families, payers, and other members of the healthcare team.
• Possess near vision acuity for accurate reading of computer screens and documentation in patient records.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Physical Requirements

• Talking

Working Conditions

• Office Setting

Salary Information
Salary is commensurate with education, skills, and relevant experience.

SECURITY AND EEO STATEMENT

Security
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.