Deputy Chief of Utilization Management

Position Summary

The Deputy Chief of Utilization Management provides executive-level strategic, clinical, regulatory, and operational leadership for the administration, oversight, and continuous improvement of utilization management (UM) functions within Oakland Community Health Network (OCHN).

Reporting directly to the Chief Administrative Officer (CAO), the Deputy Chief is responsible for advancing utilization management strategies that ensure timely, equitable, clinically appropriate, and medically necessary access to publicly funded behavioral health, intellectual and developmental disability, and substance use disorder services.

The Deputy Chief provides leadership and accountability for utilization management operations, clinical review integrity, regulatory compliance, operational performance, accreditation readiness, and continuous quality improvement.

A primary responsibility of this position is ensuring that utilization management operations comply with applicable Michigan Department of Health and Human Services (MDHHS) requirements, Medicaid managed care regulations, contractual obligations, and relevant standards established by the National Committee for Quality Assurance (NCQA) and Commission on Accreditation of Rehabilitation Facilities (CARF).

The Deputy Chief works collaboratively with executive leadership, medical directors, clinical teams, network providers, Quality Improvement, Compliance, Finance, Information Technology, and other operational departments to advance OCHN's mission and maintain a person-centered, recovery-oriented, trauma-informed system of care.

Essential Duties and Responsibilities

1. Executive Leadership and Strategic Oversight

• Report directly to the Chief Administrative Officer and provide executive leadership for assigned utilization management functions.
• Develop, implement, and evaluate utilization management strategies aligned with OCHN's organizational mission, strategic priorities, regulatory obligations, and accreditation expectations.
• Establish departmental operational priorities, performance objectives, accountability measures, and continuous improvement initiatives.
• Serve as a strategic advisor to the CAO regarding utilization trends, clinical risks, service access, regulatory compliance, accreditation readiness, and operational performance.
• Lead the development and implementation of utilization management policies, procedures, clinical review standards, and operational protocols.
• Integrate applicable NCQA and CARF standards into departmental planning, operational processes, and performance improvement activities.
• Represent Utilization Management in executive leadership meetings, interdisciplinary committees, provider network discussions, accreditation activities, and external stakeholder engagements.
• Promote a culture of accountability, collaboration, ethical decision-making, innovation, and continuous improvement.

2. Utilization Management Operations and Clinical Oversight

• Provide executive-level oversight of utilization management operations, including service authorization, concurrent review, retrospective review, utilization monitoring, and related clinical review processes.
• Ensure utilization management decisions are timely, consistent, clinically appropriate, and supported by established medical necessity criteria and applicable regulatory requirements.
• Ensure operational processes align with applicable NCQA standards governing clinical criteria, review procedures, qualified clinical decision-makers, timeliness, communication, and documentation.
• Monitor authorization workflows, identify operational inefficiencies, and implement improvements that reduce unnecessary administrative burden and improve service accessibility.
• Collaborate with clinical leadership to evaluate utilization patterns across inpatient, residential, crisis, outpatient, community-based, and other covered behavioral health services.
• Establish standardized review processes, documentation requirements, escalation procedures, and decision-making protocols.
• Ensure clinical determinations requiring licensed professional or physician review are referred to appropriately credentialed decision-makers.
• Monitor compliance with authorization and notification timeframes established by Medicaid regulations, MDHHS contracts, and applicable accreditation standards.
• Oversee corrective action planning when utilization management performance does not meet established standards.

3. NCQA Compliance and CARF Accreditation Readiness

The Deputy Chief is accountable for ensuring that assigned utilization management functions maintain continuous readiness for applicable NCQA and CARF accreditation requirements.

Responsibilities include:

• Serve as the executive operational lead for NCQA utilization management compliance within assigned departmental functions.
• Ensure utilization management policies, procedures, workflows, and monitoring activities reflect applicable NCQA standards.
• Oversee processes addressing evidence-based clinical criteria, qualified clinical reviewers, timely determinations, appropriate notifications, clinical review of adverse benefit determinations, and applicable reconsideration and appeal requirements.
• Establish monitoring processes for clinical review consistency, including inter-rater reliability activities where required.
• Lead the development, implementation, and evaluation of utilization management program effectiveness in accordance with applicable accreditation requirements.
• Support CARF accreditation readiness by integrating relevant standards concerning person-centered care, accessibility, continuity of services, individual rights, organizational performance, risk management, and continuous quality improvement.
• Collaborate with Quality Improvement, Compliance, Clinical Leadership, and other departments to maintain continuous accreditation readiness.
• Lead or participate in accreditation gap assessments, internal audits, mock surveys, documentation reviews, and corrective action planning.
• Coordinate the collection, validation, and maintenance of accreditation evidence, including policies, committee minutes, performance reports, audit findings, training records, and corrective action documentation.
• Develop and monitor corrective action plans addressing identified accreditation deficiencies or opportunities for improvement.
• Provide regular accreditation compliance and readiness updates to the Chief Administrative Officer.
• Ensure staff and relevant providers receive education regarding applicable accreditation expectations and operational responsibilities.

4. Regulatory Compliance and Contractual Accountability

• Ensure assigned utilization management operations comply with applicable MDHHS requirements, Medicaid managed care regulations, PIHP contractual obligations, and OCHN policies.
• Ensure utilization management processes align with Medicaid medical necessity standards, authorization requirements, beneficiary rights, and managed care regulations.
• Collaborate with Compliance, Quality Improvement, and Legal departments to monitor regulatory and accreditation changes and implement necessary operational adjustments.
• Support readiness for external audits, NCQA reviews, CARF surveys, regulatory reviews, and contractual monitoring.
• Oversee corrective action plans related to utilization management findings.
• Ensure appropriate documentation, record retention, confidentiality, and data integrity.
• Collaborate with appropriate departments to ensure compliance with requirements governing adverse benefit determinations, notices, appeals, and fair hearing processes.
• Promote consistent application of clinical criteria and safeguards against inappropriate service restrictions.

5. Clinical Quality and Medical Necessity Oversight

• Collaborate with the Chief Clinical Officer, Chief Medical Officer, Medical Directors, and other clinical leaders to promote evidence-based, person-centered utilization management practices.
• Support the development, review, and periodic evaluation of clinical guidelines, medical necessity criteria, and service authorization protocols in accordance with applicable NCQA standards and MDHHS requirements.
• Develop and oversee processes for monitoring consistency and reliability of clinical review decisions.
• Identify and evaluate variations in utilization patterns, service intensity, length of stay, and treatment outcomes.
• Monitor clinical and operational trends that may indicate gaps in care, barriers to access, inappropriate utilization, or opportunities for service delivery improvement.
• Support interdisciplinary case review processes for individuals with complex clinical presentations, high service utilization, or significant barriers to appropriate care.
• Promote utilization management practices that respect clinical judgment, beneficiary choice, recovery principles, and individualized treatment planning.
• Collaborate with Quality Improvement to integrate utilization management findings into broader organizational quality initiatives and applicable CARF performance improvement expectations.

6. Data Analytics, Performance Improvement, and Reporting

• Lead the development of utilization management performance dashboards, executive reports, and key performance indicators.
• Monitor authorization timeliness, utilization trends, adverse determination patterns, service expenditures, provider variation, and other operational performance measures.
• Establish monitoring and reporting processes that support applicable NCQA utilization management program evaluation requirements and CARF performance measurement and improvement standards.
• Analyze utilization data to identify emerging trends, service gaps, cost drivers, and opportunities to improve clinical and operational outcomes.
• Partner with Information Technology, Data Analytics, Finance, and Quality Improvement to strengthen reporting accuracy and operational transparency.
• Present utilization management findings and recommendations to the Chief Administrative Officer, executive leadership, and appropriate governance committees.
• Develop and monitor performance improvement initiatives with measurable objectives, implementation timelines, and defined accountability.
• Support the integration of predictive analytics, workflow automation, and technology enhancements where appropriate.

7. Provider Network Collaboration and System Coordination

• Collaborate with OCHN's provider network to promote consistent application of utilization management standards and improve coordination of services.
• Identify provider education and technical assistance needs related to authorization requirements, clinical documentation, medical necessity criteria, and applicable accreditation standards.
• Participate in provider performance reviews and discussions concerning utilization trends, service access, clinical outcomes, and operational barriers.
• Support initiatives that reduce unnecessary delays in care and strengthen transitions between levels of service.
• Work collaboratively with Access, Crisis Services, Care Coordination, and Provider Network Leadership to address systemic challenges affecting service delivery.
• Promote effective communication and collaborative problem-solving between OCHN and its contracted service providers.

8. Fiscal Stewardship and Resource Management

• Support utilization management strategies that balance clinical appropriateness, beneficiary access, service quality, and responsible fiscal stewardship.
• Collaborate with Finance and executive leadership to monitor utilization-related expenditures, budgetary trends, and service demand.
• Identify opportunities to improve resource allocation and reduce avoidable or clinically inappropriate utilization without compromising medically necessary care.
• Contribute to service capacity planning, utilization forecasting, and evaluation of emerging service needs.
• Provide recommendations to the CAO regarding benefit management, service delivery models, operational investments, and resource allocation.

9. Staff Leadership and Organizational Development

• Provide direct or delegated supervision, coaching, mentoring, and performance management for assigned utilization management leaders and staff.
• Establish clear performance expectations, accountability measures, and professional development objectives.
• Support workforce planning, recruitment, retention, succession planning, and staff competency development.
• Ensure assigned staff receive education and ongoing competency assessment related to applicable NCQA standards, CARF requirements, medical necessity criteria, regulatory obligations, and organizational procedures.
• Promote interdisciplinary collaboration, professional accountability, and a positive organizational culture.
• Lead change management initiatives associated with process redesign, technology implementation, accreditation improvements, and evolving organizational priorities.

Leadership Competencies

• Strategic Thinking: Ability to translate organizational priorities and accreditation expectations into actionable utilization management strategies.
• Clinical and Operational Judgment: Ability to evaluate complex service delivery issues while balancing clinical needs, regulatory obligations, and organizational resources.
• Regulatory and Accreditation Expertise: Strong understanding of Medicaid managed care, behavioral health utilization management, NCQA standards, CARF requirements, and applicable state and federal regulations.
• Data-Driven Decision-Making: Ability to interpret utilization trends, performance indicators, and financial data to guide improvement initiatives.
• Executive Communication: Ability to present complex information and recommendations to the CAO, senior leadership, governance bodies, accreditation reviewers, and external stakeholders.
• Change Leadership: Ability to guide teams through operational transformation and continuous improvement.
• Collaboration and Relationship Management: Ability to build effective partnerships across departments and provider organizations.
• Ethical Leadership: Commitment to beneficiary rights, equitable access, transparency, accountability, and responsible stewardship of public resources.

Minimum Qualifications

Education

• Master's degree in Healthcare Administration, Public Health, Social Work, Nursing, Psychology, Behavioral Health, Business Administration, or a closely related field.
• An equivalent combination of relevant education and extensive executive-level experience may be considered, subject to OCHN's established qualification requirements.

Experience

• Minimum of seven (7) years of progressively responsible experience in behavioral health, managed care, utilization management, clinical operations, and healthcare administration.
• Minimum of ten (10) years of management or senior leadership experience with responsibility for operational oversight, staff supervision, program performance, or regulatory compliance.
• Demonstrated experience interpreting and applying medical necessity criteria, utilization management standards, and healthcare regulatory requirements.
• Working knowledge of NCQA utilization management standards and CARF accreditation principles relevant to behavioral health service delivery.
• Experience participating in regulatory audits, accreditation reviews, quality improvement initiatives, or organizational compliance activities.
• Experience managing complex operational processes and leading cross-functional improvement initiatives.
• Experience using data analytics and performance measures to inform operational and strategic decisions.

Preferred Qualifications

• Experience working within Michigan's public behavioral health system, including a PIHP, CMHSP, or Medicaid managed care organization.
• Direct experience preparing for or participating in NCQA accreditation reviews or CARF accreditation surveys.
• Demonstrated success implementing corrective action plans and maintaining accreditation-related documentation.
• Knowledge of MDHHS behavioral health contracts, Medicaid specialty behavioral health benefits, and applicable federal managed care regulations.
• Experience with intellectual and developmental disability services, serious mental illness, serious emotional disturbance, and substance use disorder service systems.
• Professional clinical licensure, such as LMSW, RN, LPC, or psychologist licensure, where relevant to assigned responsibilities.
• Experience leading utilization management departments or large multidisciplinary clinical operations teams.
• Experience implementing utilization management technology, electronic authorization platforms, or business intelligence reporting systems.

Key Performance Expectations

Success in this position will be evaluated through measurable outcomes, including:

1. Compliance with applicable authorization processing and notification timeframes.
2. Consistency, accuracy, and defensibility of utilization management decisions.
3. Demonstrated adherence to applicable NCQA utilization management standards.
4. Effective integration of relevant CARF standards into assigned operations and performance improvement activities.
5. Continuous accreditation readiness and successful completion of assigned NCQA and CARF review responsibilities.
6. Timely completion and demonstrated effectiveness of accreditation-related corrective action plans.
7. Improvement in operational efficiency and reduction of avoidable administrative delays.
8. Timely identification and resolution of regulatory or contractual compliance concerns.
9. Effective monitoring of service utilization, clinical trends, and resource allocation.
10. Implementation of measurable quality and performance improvement initiatives.
11. Improved collaboration and responsiveness with contracted providers and internal stakeholders.
12. Development, engagement, and performance of assigned utilization management staff.
13. Protection of beneficiary rights and timely access to medically necessary services.
14. Timely, accurate, and actionable reporting to the Chief Administrative Officer on departmental performance, regulatory compliance, accreditation readiness, and operational risks.

Decision-Making Authority

The Deputy Chief of Utilization Management exercises delegated executive authority over assigned operational functions, personnel, performance improvement activities, accreditation readiness initiatives, and utilization management operations.

The position reports directly to the Chief Administrative Officer and is accountable for the performance, compliance, and effectiveness of assigned utilization management functions.

The Deputy Chief may recommend operational policy changes, resource allocation strategies, corrective actions, and process improvements to the Chief Administrative Officer and executive leadership.

Authority to make clinical determinations, issue adverse benefit determinations, or approve exceptions to established criteria must remain consistent with applicable professional licensure, regulatory requirements, organizational policies, and formally delegated responsibilities.