The Utilization Review(UR) Director (RN) is responsible for ensuring that all behavioral health patients receive the appropriate level of care, and that all services rendered meet medical necessity, payer requirements, Texas Behavioral Health regulations, and DNV accreditation standards.

The UR Director performs utilization review activities, concurrent reviews, precertifications, and discharge-related authorization functions to support timely reimbursement and high-quality patient care.

Essential Duties:

1.Utilization Management & Medical Necessity

• Conduct admission, continued-stay, and discharge reviews for all patients based on:
  • InterQual, MCG, or payer-specific medical necessity criteria.
  • CMS Conditions of Participation (where applicable).
  • DNV NIAHO Behavioral Health standards.
• Validate appropriate level of care (inpatient, PHP, IOP, detox, residential).
• Identify and communicate variances to medical necessity, collaborating with providers to resolve clinical or authorization barriers.

2.Insurance & Authorization Management

• Initiate pre-certifications for admissions and transfers.
• Perform concurrent reviews with commercial, Medicaid, Medicare Advantage, and managed care organizations.
• Submit clinical documentation within required time frames to prevent denials.
• Manage peer-to-peer requests and escalate cases to physician advisors as needed.
• Track and document authorization numbers, approved days, and review dates in EMR and UR software.

3.Compliance & Accreditation (DNV / Texas-specific)

• Ensure UR processes comply with:
  • DNV NIAHO/ISO 9001 requirements for utilization management.
  • Texas Administrative Code Title 25Behavioral Health Facility regulations.
  • CMS, EMTALA (if applicable), and payer rules.
• Participate in audits, tracer activities, and performance improvement projects.
• Maintain accurate and complete documentation that meets DNV documentation standards.

4.Interdisciplinary Collaboration

• Work with physicians, nursing, case management, therapy, social work, and admissions to coordinate patient flow and progression of care.
• Attend daily treatment team meetings on assigned units.
• Communicate authorization status, updates, and denials to clinical teams.

5.Denial Prevention & Management

• Identify potential denial risks early and intervene proactively.
• Assist with preparation of denial appeals, supplying clinical summaries and supporting documentation.
• Work with billing and revenue cycle to ensure claims accuracy and timely submission.

6.Documentation & Data Management

• Enter all reviews, payer communications, and clinical updates into the EMR/UR tracking system.
•  Maintain UR logs, KPIs, and dashboards for:

o LOS monitoringo Denial rateso Approval trendso Payer mix and reimbursement

o Report trends to leadership for process improvement

This is 100% on-site, located in Midland, Texas.

Qualifications:

• Current Texas RN license (unencumbered) is required.
• Minimum 2 years psychiatric/behavioral health nursing experience is required.
• Experience with utilization review, case management, or managed care is required.
• Experience with Medicaid/Medicare behavioral health authorization processes is required.
• Knowledge of InterQual/MCG criteria.
• Strong understanding of behavioral health diagnoses, treatment modalities, and levels of care.
• Excellent communication and negotiation skills.
• Prior UR/UM experience in a Texas behavioral health facility is strongly preferred.
• Familiarity with DNV Accreditation (NIAHO/ISO 9001) is strongly preferred.
• Experience with EMRs such as Epic, Cerner, MediTech, or Sigmund is preferred.
• Clinical assessment and critical thinking
• Knowledge of utilization review criteria
• Strong professional communication
• Time management and organization
• Understanding of behavioral health regulations
• Accuracy and attention to detail
• Collaboration and conflict resolution
• Ethical decision-making

Working at Permian Basin Behavioral Health Center (PBBHC) offers the rare opportunity to be a part of a brand-new, mission-driven organization that is transforming access to behavioral healthcare across West Texas and Southeastern New Mexico. Team members play a meaningful role in building programs, shaping culture, and directly impacting lives in a growing region with a strong sense of purpose and collaboration by transforming lives and restoring hope.

Living inMidland, Texas adds to the appeal, offering a high quality of life with affordable housing, short commutes, excellent schools, and a welcoming community. Midland blends small-city convenience with big-opportunity energy. Featuring a vibrant arts scene, outdoor recreation, and easy access to regional travelmaking it an ideal place to grow both professionally and personally.