Utilization Review Analyst HYBRID (PCN 1542)

Overview Job location: Troy, MI (Full Time Professional) Salary Range: $56,165.00 to $70,206.00 Annually 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. Responsibilities 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. Education and Licensure Education: Master’s degree in a mental health field. Licensing/Certifications: 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), or Registered Nurse (RN). Additional License Requirement: Must maintain Child Diagnostic and Treatment Professional (CDTP) eligibility, including 24 hours of annual child-specific training. Experience Experience Requirements: Minimum of five (5) years relevant experience providing services to Adults with Mental Illness, Intellectual or Developmental Disabilities, Substance Use Disorder and/or children with Serious Emotional Disturbance 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 with utilization of the MCG Parity Tool. Experience within the Oakland Community Health Network (OCHN) provider network. Knowledge Knowledge of the Michigan Mental Health Code. Medicaid rules, regulations, and Michigan Medicaid Provider Manual. Managed Care and utilization management principles. Job Competencies Demonstrated strong interpersonal skills with the 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. Core Competencies Integrity/Building Trust: Interacting with others with confidence in the organization’s mission and values, and adhering to codes of conduct. Customer Focus: Making customers and their needs a primary focus and developing productive relationships. Continuous Learning: Identifying learning opportunities and applying new knowledge on the job. Work Standards: Setting high performance standards and accountability. Communication: Clearly conveying information to engage and inform audiences. Additional Information Hybrid (onsite/remote) work schedule available. 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 outside of standard office hours. 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 an equal opportunity employer that embraces and encourages our employees’ differences. #J-18808-Ljbffr Oakland-Community-Health-Network