Utilization Management Clinical Analyst HYBRID (PCN 1534)

Utilization Management Clinical Analyst

The Utilization Management Clinical Analyst conducts prospective reviews of authorization requests to determine medical necessity and clinical appropriateness of behavioral health services in accordance with Level of Care 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, person-centered care through collaboration with providers and internal stakeholders.

Essential Functions

• Apply advanced clinical expertise, behavioral health best practices, medical necessity criteria, Medicaid and PIHP requirements, regulatory standards, and organizational policies to determine the clinical appropriateness of behavioral health and intellectual/developmental disability service authorization requests.
• Independently perform comprehensive medical necessity reviews of service authorization requests by analyzing complex clinical information, assessments, treatment plans, and supporting documentation to determine the appropriate amount, scope, duration, intensity, and level of care needed to meet assessed needs, ensuring decisions are clinically sound, timely, well-documented, and consistent with person-centered planning principles and applicable benefit requirements.
• Ensure authorization decisions comply with applicable federal and state regulations, Medicaid Provider Manual requirements, PIHP contractual obligations, parity requirements, evidence-based clinical guidelines, and organizational policies and procedures.
• 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 Individualized Plan of Service (IPOS).
• 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 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) Must maintain Child Diagnostic and Treatment Professional (CDTP) eligibility, including 24 hours of annual child-specific training.

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. Preference for CADC or CAADC credentials.

Knowledge Requirements: Michigan Mental Health Code. Medicaid guidelines, regulations, and Michigan Medicaid Provider Manual. Manage Care Principles and Utilization Management. Preference for knowledge of the PIHP responsibilities for utilization management.

Job Specific Competencies/Skills: Ability to work effectively in a team environment. High level of understanding of various treatment processes. Effective communication skills (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.

Oakland Community Health Network