Utilization Management Clinical Analyst HYBRID (PCN 1543)

Job Title

Promotes appropriate, effective, and efficient use of resources via prospective, concurrent, and retrospective reviews, program and network recommendations. The scope of this position includes the review of clinical care and treatment plans by staff in the OCHN SUD provider network and acute care settings.

Essential Functions

Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.

Conduct prospective reviews for service authorizations as identified by OCHN.

Conduct concurrent clinical case reviews as requested.

Conduct retrospective reviews of service provision to ensure services were provided in the appropriate amount, scope, and duration to reasonably achieve goals as outlined in the Individualized Plan of Service.

Analyzes records to determine legitimacy of admission, treatment, and length of stay in residential settings 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.

Review and approve initial and re-authorization requests from substance use disorder providers within the OCHN provider network.

Review telephonic requests for transitions between levels of care and facilitate referral to the next provider.

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 to ensure appropriate communication and discharge planning occurs.

Accountable for timely and comprehensive review of clinical data with concise documentation, decisions, and rationale.

Analyze data and management reports. Provide recommendations for improvement plans as well as recognition for exemplary practices.

Participate in workgroups and committees with other OCHN Teams, such as involvement in Access, Quality Management, or benefits coordination initiatives, etc.

Perform other duties as assigned.

Job Requirements and Qualifications

Education: Master's degree in the mental health field or a relevant discipline required.

Training Requirements (licenses, programs, or certificates): State of Michigan license, certification and / or registration as, Psychologist (LLP, LP), Social Worker (LMSW), Counselor (LPC), Marriage and Family Therapist (LMFT) or Nurse (RN). CADC, CAADC, or development plan for the CADC/CAADC credentials.

Experience Requirements: Minimum of five (5) years relevant experience providing services to Adults with Substance Use Disorder. Preference for experience in the OCHN network.

Job Specific Competencies/Skills: Demonstrated effective interpersonal skills. Demonstrated ability to work effectively in a team environment. Demonstrated effective written and oral communication skills. Demonstrated effective computer skills. Preferred competencies: 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. Demonstrated understanding of the application and outcome measurement of Substance Use Disorder Practices. Knowledge of American Society of Addictions Medications (ASAM) Criteria. Knowledge of substance use disorders and DSM-5. Working knowledge of HIPPA and 42-CFR rules and compliance.

Oakland Community Health Network's Core Competencies

Interacting with others in a way that gives them confidence in one's intentions and those of the organization; demonstrating loyalty to the organization and its mission and values; maintaining social, ethical, and organizational norms; firmly adhering to codes of conduct and ethical principles. (Integrity/Building Trust) Making customers and their needs a primary focus of one's actions; developing and sustaining productive customer relationships, recognizing that the ultimate customer is the person served. (Customer Focus) Actively identifying new areas for learning; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill on the job and learning through their application. (Continuous Learning) Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence in addition to consciously adopting organizational standards of excellence. (Work Standards) Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message. (Communication)

Other Information

Must have available means of transportation to and from OCHN and for required offsite meetings or site visits. Must be available for meetings and events which may occur outside of standard office hours. Work performed primarily in an office environment. Hybrid (onsite/remote) work schedule available. The ideal candidate must be able to complete all physical requirements of the job with or without a reasonable accommodation.

Oakland Community Health Network