Utilization Review Supervisor (PCN 1547)

Oakland Community Health Network•Troy, MI

2d•$70,298 - $87,873•Hybrid

About The Position

The Supervisor of Utilization Review promotes appropriate, effective, and efficient use of resources related to the Utilization Review Team. The scope of this position includes the supervision of Utilization Review Analysts and the review of clinical care in the OCHN provider network.

Requirements

Master's degree in mental health field.
State of Michigan license, certification and / or registration as, Psychologist (LLP, LP), Social Worker (LMSW), Counselor (LPC), Marriage and Family Therapist (LMFT).
Minimum of 5 years relevant experience providing services to persons with Mental Illness, Intellectual or Developmental Disabilities, Substance Use Disorder and/or Serious Emotional Disturbance.
Knowledge of the Michigan Mental Health Code.
Understanding of Medicaid rules, regulations, and Michigan Medicaid Provider Manual.
Understanding of utilization review.
Demonstrated effective interpersonal skills.
Demonstrated ability to work effectively in a team environment.
Demonstrated effective written and oral communication skills.
Demonstrated effective computer skills.

Nice To Haves

CADC, CAADC, or Development Plan preferred.
Preference for experience in a supervisory/leadership role.
Preference for experience in the OCHN network.
Preference for knowledge of the OCHN Utilization Review Manual and Protocols.
Demonstrated experience in quality assurance and quality monitoring.
Demonstrated experience in the application of medical necessities.
Demonstrated experience in data analysis and outcome measurement.
Demonstrated understanding of the application and outcome measurement of Evidence Based Practices.

Responsibilities

Performs administrative and supervisory duties related to all functions of the Utilization Review Analysts.
Monitors and evaluates specialist approvals, specialist reviews, audits, and other assigned reviews conducted by the Utilization Review Team.
Demonstrates an applied commitment to the values as well as knowledge and skills in person served-oriented practices as well as innovations in support, service, treatment, and care practices.
Assures adequate supervision / evaluation processes for all assigned staff members and delegate responsibilities as appropriate.
Assures adequate orientation for new employees.
Provides direction to individual employees on Utilization Review Team through leadership, facilitation, teaching, coordination, problem solving, conflict resolution, and coaching.
Actively participates in the professional development of all subordinates through the Performance Management process, ensuring that all performance appraisals are completed on time.
Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness for acute care and State Facility authorizations.
Analyzes records to determine legitimacy of admission, treatment, and length of stay in acute care and State facilities to comply with government and insurance company reimbursement policies analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning treatment and length of stay.
Compares inpatient medical records to established criteria and confers with OCHN provider personnel as well as personnel in acute care / State facilities, and other professional staff to determine legitimacy of treatment and length of stay.
Determines continued stay review dates according to established clinical protocols and diagnostic criteria.
Conducts continued stay reviews and determines continued authorization status.
Coordinates with OCHN providers and acute care / State facility providers to ensure appropriate communication and discharge planning occurs.
Is accountable for timely and comprehensive review of clinical data with concise documentation, decisions, and rationale.
Participates in workgroups and committees with other OCHN Teams, such as involvement in Access, Quality Management, or benefits coordination initiatives, etc.
Oversees the development and finalization of all audit tools utilized by the team and assists in the annual creation of the audit schedule for the Utilization Review Team.
Manage reports and data for audits and complete audit preparation.
Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.
Provide utilization review support/coaching/training to OCHN’s provider network, as needed.
Develop and Analyzes data and manages reports. Provides recommendations for improvement plans as well as recognition for exemplary practices.
Participates in workgroups and committees with other OCHN Teams, such as involvement in Clinical, Quality Management, Finance, etc.
Supervise, develop and update clinical policies, procedures, and protocols related to UM/UR.
Participate in and guide UR Analysts, providers and hospital performance monitoring related to support and services, high risk cases, clinical audits, chart reviews, acute care, coordination, and discharges.
Participates in management level meetings, annual goals, and updates.
Participate in maintaining, developing, implementing, and monitoring procedures, policies, and practices required for accrediting bodies, such as NCQA and HSAG.
Supports and consults team and Due Process Coordinator regarding any due process concerns or issues.
Facilitate Inter-Rater Reliability testing for UM/UR Department to ensure consistency and reliability in the UM process.
Oversee and manage Over-Under Utilization data analysis work group.
Supports the efforts of the UR team participating in the Diversity, Equity, and Inclusion activities.
Knowledge of mandated timeliness related to authorizations, denials and appeals from MDHHS and NCQA.
Performs other duties as assigned.