Director of Utilization Management (PCN 1527)

The Director of Utilization Management (UM) is responsible for the strategic direction, continuous improvement, and oversight of the UM Department. This position will ensure individuals receive appropriate services in accordance with the assessment of need, and Individual Plan of Service, with consistent review of service utilization and cost reporting. The Director is involved in quality improvement efforts in compliance with all corporate policies, provider contracts, and state and federal legislative mandates and accountable for meeting organizational utilization, quality, access, and cost-containment goals.

• Leads the communication, coordination, implementation and management of service initiatives, projects, and contract requirements on behalf of Oakland Community Health Network (OCHN) relative to Utilization Management. This includes research, input from persons served and the community, and reporting.
• Ensures compliance with all relevant standards and regulations, leads the development of Utilization Management policies, protocols, procedures, and practices guidelines and coordinates implementation across the Service Network.
• Provides analysis and reports of significant utilization trends, patterns, and impact to resources with quarterly reporting to the OCHN Board.
• Provides supervision for the manager of UM
• Leads the Utilization Management Committee.
• Analyzes utilization data; makes improvements; provides training /education, as needed; and ensures that the Utilization Management Program Description and Manual is updated and revised, annually.
• Participates in and provides recommendations to the Innovation and Operations Committee. 
• Identify, develop, prioritize, and implement training for staff to have the necessary skills to implement OCHN’s strategic plan.
• Ensures that necessary OCHN information is communicated to and from the Provider Network, including project implementation, progress, and barriers.
• Collaborates with the Medical Director regarding medical necessity determinations, utilization trends, appeals, and clinical policy development.
• Identify emerging utilization trends and recommend interventions.
• Participates in the development of monitoring tools and analysis of the monitoring data. Collaborates with all parties to ensure validity and reliability testing has been done on the monitoring tools and outcomes. Informs Providers of the need for improvement plans as well as recognition for exemplary practices.
• Collaborates with Finance on forecasting and cost containment initiatives.
• Resolves systems issues identified by Customer Service staff and other members of the Service Network Team, including communicating relevant information, analyzing data / trends, and making recommendations, arranging provider education / training, and ensuring development and evaluation of improvement plans.
• Ensures UM performance indicators are monitored, and corrective actions are implemented when targets are not met.
• Resolves Provider issues/complaints, including facilitation of the Dispute Resolution process and Appeals process, if needed.
• Provides leadership, coaching, performance management, and professional development for UM management and staff.
• Works across teams relative to OCHN’s participation in local, state, and federal collaborative activities as well as implementation of identified initiatives and projects that affect the Service Network.
• Performs other duties as assigned.

Education:

• Master's degree in the mental health field.

Training Requirements (licenses, programs, or certificates):  

• State of Michigan licensure as Psychologist (LLP -Limited Licensed Psychologist), Social Worker (LMSW - Licensed Masters Social Worker), Counselor (LPC -Licensed Professional Counselor), Registered Nurse (RN) with ambulatory and inpatient Behavioral Health experience.

Experience Requirements:

• Minimum of 3-5 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.
• Experience within a Community Mental Health Services Program (CMHSP), Prepaid Inpatient Health Plan (PIHP), Managed Care Organization (MCO), hospital, or behavioral health setting.  

Preferred Experience:

• Demonstrated leadership skills in a managerial position in the public or private sector.
• MCG Parity Tool

Knowledge Requirements

• Michigan Mental Health Code.
• Medicaid rules and regulations.
• Community Mental Health service delivery system CMHSP & PIHPs
• Utilization Management and Review Practices.
• NCQA (National Committee for Quality Assurance) and HSAG (Health Services Advisory Group) standards (UM).
• Medicaid Provider Manual

Job Specific Competencies/Skills

• Project management.
• Experience in leading workgroups and teams across a Network of Providers.
• Data Analysis.
• Ability to work in a team.
• Problem Solving Skills.
• Effective written and oral communication.
• Experience and knowledge with Microsoft, Edge, Chrome, MS Teams, Excel, and Dashboards

Preferred Competencies

• Budget preparation and oversight.
• Evaluation of Behavioral Health Service Code Utilization.
• Working knowledge of National Coverage Determination Tool (MCG -Milliman Care Guidelines-Indicia).
• Working knowledge of the UM Denial/Appeal Process.

Special Information (Travel required, physical requirements, on-call 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.
• Work performed primarily in an office environment. 
• Hybrid (onsite/remote) work schedule available.