Utilization Specialist - Hybrid

At EMC Behavioral Health, we believe mental health begins with passionate care, intentional connection and the power of evidence-based practice. Guided by our mission to deliver the highest quality, client-centered care and our vision to equip individuals with innovative tools for lasting mental wellness, we serve as a trusted partner to clients, families, and communities seeking meaningful change. If your driven by purpose, energized by advocacy, and committed to ensuring that care is both clinically sound and deeply human, you will find your calling here at EMC.

Position Summary:
The Utilization Specialist is a key driver of EMC's clinical excellence, ensuring each client receives timely, appropriate, and medically necessary care. This role seamlessly integrates care coordination, clinical assessment, and utilization management to support strong recovery outcomes, uphold regulatory and payer requirements, and strengthen overall operational efficiency. We're seeking a clinically grounded professional with sharp analytical insight, exceptional communication skills, and a genuine commitment to serving diverse populations within a dynamic behavioral health setting.

What You'll Do:
In this high-impact role, you will help ensure clients receive the right care at the right time while supporting EMC's commitment to clinical excellence. Your responsibilities will include:

Care Coordination & Client Support:

• Coordinate appointments, therapy sessions, referrals, and supportive services
• Monitor client progress, medication adherence, and engagement in programming
• Partner with families, caregivers, and interdisciplinary teams to ensure continuity of care

Clinical Assessment & Treatment Planning:

• Conduct comprehensive initial and ongoing assessments
• Support clients with the individualized recovery plans and evidence-based coping strategies
• Serve as an internal resource on medical necessity, utilization workflows, and clinical best practices

Utilization Review & Case Management:

• Lead prior authorizations, concurrent reviews, and discharge planning
• Ensure full compliance with payer guidelines, authorization limits, Medicaid/Medicare rules, and regulatory requirements
• Coach and train team members on documentation, compliance standards, and evolving regulations
• Review utilization trends and recommend process improvements or efficiencies

Documentation, Reporting & Compliance:

• Maintain accurate, timely documentation in the EHR and complete required assessments (CANS/ANSA)
• Prepare and submit monthly utilization and outcomes reports
• Participate in monthly UM meetings, audits, and continuous quality improvement initiatives
• Consistently uphold HIPAA and all state/federal behavioral health regulations

Additional Responsibilities:

• Respond to call-outs, client emergencies and inquiries in alignment with protocols, including occasional after-hours support
• Support clinic outreach through community engagement, referral coordination, and collaboration with external partners
• Perform other duties as assigned

Minimum Qualifications:

• Bachelor’s degree in psychology, sociology, criminal justice, education or other related field (Master’s degree preferred)
• Active QMHP certification and HIPAA training
• CANS/ANSA certification (or willing to obtain)
• At least one year experience in behavioral health, case management or a clinical support role (2-3 years in a utilization management role preferred)
• Strong understanding of managed care, medical necessity criteria, and Medicaid authorizations
• Excellent documentation, assessment and critical-thinking skills
• Ability to collaborate effectively across clinical and administrative teams

Who Thrives in This Role:
You'll be a strong fit for EMC if you are:

• Mission-driven and committed to compassionate, high-quality care
• A confident communicator who builds rapport easily
• Detail-oriented, organized, and comfortable balancing multiple priorities
• Skilled at blending clinical judgment and operational decision-making
• Dedicated to ethical practice and ongoing professional development

Why Join EMC Behavioral Health:

• Make a meaningful difference in clients' lives every day
• Join a collaborative, supportive clinical team
• Access opportunities for professional growth, mentorship, and certification
• Be a part of a mission-driven organization that truly values quality, compassion, and innovation

Schedule & Work Environment:

• Full-time, Monday-Friday with limited on-call responsibilities
• Hybrid clinical/administrative position in an outpatient behavioral health setting
• 2 days onsite in our Northwest Houston office
• Requires regular use of EHR systems, reporting tools, and standard office equipment

Compensation & Benefits:

• $52,000 to $65,000 per year, depending on education and experience
• Group Health insurance options, both employee and employer paid
• Paid Time Off

Equal Opportunity Employer:
EMC Behavioral Health is an Equal Opportunity Employer and is committed to fostering a diverse, inclusive, and equitable work environment. We welcome applicants of all backgrounds, identities, and experiences.