Utilization Review Analyst HYBRID (PCN 1542)

Job Description

Job Description

Job Summary

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.

Essential Functions

• 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.

Job Requirements and Qualifications

Education :

• Master's degree in mental health field.

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)

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.

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.
• Experience withutilizationof the MCG Parity Tool.
• Experience within the Oakland Community Health Network (OCHN) provider network.

Knowledge Requirements: 

• Knowledge of the Michigan Mental Health Code. 
• Medicaid rules, regulations, and Michigan Medicaid Provider Manual. 
• Managed Careandutilizationmanagementprinciples.
• Preference for knowledge of thePIHP responsibilities forutilizationmanagement.  

Job Specific Competencies/Skills:

• 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.

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)

Additional Information

(Travel required, physical requirements, schedules, etc.):

• 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.
• 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.

OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees’ differences. This includes (but is not limited to) ability, age, color, family type, gender expression and identity, individual expression, medical conditions, national origin, pregnancy, race, religion, sexual orientation, veteran status, and all other diverse and wonderful characteristics.