Utilization Management Clinical Analyst - SUD HYBRID (PCN 1543)

Job Description

Job Description

Job Summary

The Utilization Management Clinical Analyst – Substance Use Disorder (SUD) conducts prospective and concurrent reviews of substance use disorder authorization requests to determine medical necessity and clinical appropriateness of behavioral health services in accordance with American Society of Addiction Medicine (ASAM) Level Need, Medicaid guidelines, MDHHS requirements, and the Michigan Mental Health Code. This position applies clinical expertise and evidence-based criteria to support timely utilization management decisions, promote appropriate resource utilization, and ensures quality, individualized treatment through collaboration with providers and internal stakeholders. The scope of this position includes the review of clinical care and treatment plans for the SUD provider network.

Essential Functions

• • Apply advanced clinical expertise, best practices, medical necessity criteria, Medicaid and PIHP requirements, regulatory standards, and organizational policies to determine the clinical appropriateness of SUD authorization requests.
  • Independently perform comprehensive medical necessity reviews of prospective and concurrent service authorization requests by analyzing complex clinical information, assessments, treatment plans, and supporting documentation to determine the appropriate amount, scope, duration, intensity, and ASAM level of care needed to meet assessed needs, ensuring decisions are clinically sound, timely, well-documented, and consistent with individualized treatment planning principles and applicable benefit requirements.
  • Ensure authorization decisions comply with applicable federal and state regulations, Medicaid Provider Manual requirements, ASAM guidelines, PIHP contractual obligations, evidence-based clinical guidelines, and organizational policies and procedures.
  • 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 requests for transitions between ASAM levels of care and facilitate referral to the next SUD provider.
  • Determines continued stay review dates according to established clinical protocols and diagnostic criteria.
  • Complete retrospective utilization reviews to evaluate whether services provided were medically necessary, clinically appropriate, adequately documented, and delivered in the appropriate amount, scope, duration, and intensity to achieve the goals identified in the treatment plan.
  • Participate in the development, validation, implementation, and continuous improvement of utilization management policies, clinical protocols, decision-support tools, audit processes, and workflow enhancements.
  • Collaborate with internal clinical teams, provider organizations, and community partners to facilitate effective care coordination, timely communication, discharge planning, and continuity of care.
  • Participate in interdisciplinary committees, quality improvement initiatives, utilization management workgroups, and external stakeholders to support system-wide clinical quality and compliance.
  • Monitor and analyze utilization patterns, service trends, and authorization data to identify opportunities for quality improvement, ensure appropriate utilization, support regulatory compliance, and inform utilization management practices.
  • Maintain current knowledge of behavioral health standards of care and state and federal policy and regulations.
  • Perform other duties and special projects 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):

• • 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)
    • Registered Nurse (RN)
  • CADC, CAADC, or development plan for the CADC/CAADC credentials.

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• Experience Requirements:

  • Minimum of three (3) years of relevant post-graduate clinical experience providing services to adults with mental illness, intellectual or developmental disabilities, and/or substance use disorders, as well as children with serious emotional disturbance and/or intellectual or developmental disabilities.
  • Preference for knowledge of the PIHP responsibilities forutilizationmanagement related toSubstance Use Disorderservices.

  Preferred Experience

  • Experience within a Community Mental Health Services Program (CMHSP), Prepaid Inpatient Health Plan (PIHP), Managed Care Organization (MCO), hospital, or behavioral health setting.

  Knowledge Requirements

  • Michigan Mental Health Code. 
  • Medicaid guidelines, regulations, and Michigan Medicaid Provider Manual. 
  • Manage Care Principles and Utilization Management. 
  • 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.

  Job Specific Competencies/Skills:

  • Ability to work effectively in a team environment.
  • High levelof understanding of various treatment processes.
  • Effective communication skills (written, oral and computer)
  • Ability to apply knowledge and evidence-based practices to complex decision-making situations.

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

(Travel required, physical requirements, and so on):

• 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.