Utilization Management Clinical Analyst HYBRID (PCN 1534)
About The Position
The Utilization Management Clinical Analyst conducts prospective reviews of authorization requests to determine the medical necessity and clinical appropriateness of behavioral health services in accordance with Level of Care Need, Medicaid guidelines, MDHHS requirements, and the Michigan Mental Health Code. The role applies clinical expertise and evidence-based criteria to support timely utilization management decisions, promote appropriate resource utilization, and ensure quality, person-centered care through collaboration with providers and internal stakeholders. The analyst independently reviews complex clinical information, assessments, treatment plans, and supporting documentation to determine the appropriate amount, scope, duration, intensity, and level of care. The role also conducts retrospective utilization reviews and supports the development and improvement of utilization management policies, protocols, decision-support tools, audits, and workflows. The analyst collaborates with internal teams, provider organizations, community partners, committees, and external stakeholders to support care coordination, quality improvement, and compliance.
Requirements
- Master’s degree in a mental health field or relevant discipline.
- Current, unrestricted State of Michigan professional license as an LLP, LP, LMSW, LPC, LMFT, or RN; license must be maintained.
- Maintain Child Diagnostic and Treatment Professional (CDTP) eligibility, including 24 hours of annual child-specific training.
- At least three years of relevant post-graduate clinical experience providing services to adults with mental illness, intellectual or developmental disabilities, and/or substance use disorders, and to children with serious emotional disturbance and/or intellectual or developmental disabilities.
- Knowledge of the Michigan Mental Health Code.
- Knowledge of Medicaid guidelines, regulations, and the Michigan Medicaid Provider Manual.
- Knowledge of managed care principles and utilization management.
- Ability to work effectively in a team environment.
- Strong understanding of various treatment processes.
- Effective oral and computer communication skills.
- Ability to apply knowledge and evidence-based practices to complex decision-making situations.
- Available means of transportation to and from OCHN and required offsite meetings or site visits.
- Availability for meetings and events that may occur outside standard office hours.
- Ability to complete the physical requirements of the job, with or without reasonable accommodation.
Nice To Haves
- Experience in a Community Mental Health Services Program (CMHSP), Prepaid Inpatient Health Plan (PIHP), Managed Care Organization (MCO), hospital, or behavioral health setting.
- CADC or CAADC credentials preferred.
- Knowledge of PIHP responsibilities for utilization management preferred.
Responsibilities
- Apply clinical expertise, behavioral health best practices, medical necessity criteria, Medicaid and PIHP requirements, regulatory standards, and organizational policies to determine the clinical appropriateness of behavioral health and intellectual/developmental disability service authorization requests.
- Independently conduct comprehensive medical necessity reviews of authorization requests, analyzing clinical information, assessments, treatment plans, and supporting documentation to determine appropriate amount, scope, duration, intensity, and level of care.
- Ensure authorization decisions are timely, well-documented, clinically sound, person-centered, and consistent with applicable benefit requirements.
- Ensure decisions comply with federal and state regulations, Medicaid Provider Manual requirements, PIHP contractual obligations, parity requirements, evidence-based clinical guidelines, and organizational policies and procedures.
- Complete retrospective utilization reviews to evaluate medical necessity, clinical appropriateness, documentation, and service amount, scope, duration, and intensity relative to Individualized Plan of Service goals.
- Participate in developing, validating, implementing, and continuously improving utilization management policies, clinical protocols, decision-support tools, audit processes, and workflows.
- Collaborate with internal clinical teams, provider organizations, and community partners to facilitate care coordination, timely communication, discharge planning, and continuity of care.
- Participate in interdisciplinary committees, quality improvement initiatives, utilization management workgroups, and external stakeholder activities.
- Monitor and analyze utilization patterns, service trends, and authorization data to identify quality improvement opportunities, support appropriate utilization and regulatory compliance, and inform utilization management practices.
- Maintain current knowledge of behavioral health standards of care and state and federal policies and regulations.
- Perform other duties and special projects as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
