Utilization Review Analyst HYBRID (PCN 1542)

Oakland Community Health Network•Troy, MI

32d•$56,165 - $70,206•Hybrid

About The Position

Utilization Review Analyst conducts prospective, concurrent, and retrospective reviews of service authorizations, ensuring the appropriate, effective, and efficient use of acute psychiatric inpatient and state facility services. Reviews clinical documentation to determine medical necessity and authorize service in accordance with Michigan Medicaid Provider Manual requirements, organizational policies, and applicable regulatory standards. Collaborates with network providers, hospitals, and interdisciplinary teams to support timely authorization decisions, continuity of care, and appropriate transitions across the behavioral health continuum while maintaining accurate clinical documentation and regulatory compliance.

Requirements

Master's degree in mental health field.
Possession and maintenance of a current, unrestricted State of Michigan professional license in one of the following disciplines: Licensed Psychologist (LLP or LP), Licensed Master's Social Worker (LMSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), or Registered Nurse (RN).
Must maintain Child Diagnostic and Treatment Professional (CDTP) eligibility, including 24 hours of annual child-specific training.
Minimum of five (5) years relevant experience providing services to Adults with Mental Illness, Intellectual or Developmental Disabilities, Substance Use Disorder and/or children with Serious Emotional Disturbance or Intellectual or Development Disabilities.
Knowledge of the Michigan Mental Health Code.
Knowledge of Medicaid rules, regulations, and Michigan Medicaid Provider Manual.
Knowledge of Managed Care and utilization management principles.
Demonstrated strong interpersonal skills with a proven ability to collaborate effectively in cross-functional and team-oriented environments.
Skilled in negotiation and stakeholder engagement, fostering productive relationships, and achieving mutually beneficial outcomes.
Excellent written and verbal communication skills, with the ability to convey complex information clearly and professionally.
Proficient in computer applications and project management practices, ensuring efficient coordination, execution, and successful delivery of initiatives.

Nice To Haves

Experience within a Community Mental Health Services Program (CMHSP), Prepaid Inpatient Health Plan (PIHP), Managed Care Organization (MCO), hospital, or behavioral health setting.
Experience with utilization of the MCG Parity Tool.
Experience within the Oakland Community Health Network (OCHN) provider network.
Preference for knowledge of the PIHP responsibilities for utilization management.

Responsibilities

Conduct concurrent utilization reviews of behavioral health services for acute psychiatric hospitals, state psychiatric facilities, and other levels of care to determine medical necessity, appropriateness of admission, continued stay, and discharge in accordance with Michigan Medicaid Provider Manual requirements and applicable regulatory requirements.
Review and analyze clinical documentation using established medical necessity criteria, clinical guidelines, contractual requirements, and reimbursement policies to make authorization determinations for inpatient behavioral health services.
Collaborate with network providers, acute care hospitals, state psychiatric facilities, and interdisciplinary treatment teams to facilitate utilization review activities, continuity of care, and effective discharge planning.
Apply evidence-based utilization management criteria and clinical protocols to establish continued stay review intervals and determine authorization status.
Document clinical reviews, authorization decisions, and supporting rationale accurately and within required timeframes in accordance with organizational, contractual, and accreditation standards.
Utilize clinical knowledge of behavioral health services, Michigan Medicaid Provider Manual requirements and organizational policies to ensure appropriate utilization of services and compliance with applicable regulations.
Participate in quality improvement initiatives, interdisciplinary workgroups, provider collaboration, audits, appeals, and other utilization management and review activities to support organizational performance and regulatory compliance.
Perform additional duties and special projects assigned.