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Utilization Management Supervisor

Oakland Community Health Network
2 hours ago
Full-time
Remote friendly (Troy, Michigan, United States)
United States
$70,298 - $87,873 USD yearly
Master's

Job Summary

The Supervisor of Utilization Management (UM) provides leadership, clinical oversight, and operational direction for the UM team, ensuring timely, consistent, appropriate, and compliant utilization management practices. This position is responsible for supervising and developing UM Clinical Analysts; overseeing the quality, consistency, timeliness, and appropriateness of utilization management activities; and ensuring compliance with applicable organizational, regulatory, contractual, and accreditation requirements. The Supervisor of UM applies clinical expertise, utilization management standards, business rules, and regulatory requirements to support appropriate, effective, and efficient use of services and resources across the OCHN provider network.

The Supervisor of UM oversees prospective, concurrent, and retrospective utilization management activities; monitors utilization and performance data; leads audit and quality improvement activities; and supports the development, implementation, and maintenance of UM policies, procedures, protocols, and processes. The position works collaboratively with providers, community partners, and internal departments to address complex and high-risk cases, promote effective care coordination, identify opportunities for improvement, and ensure services are delivered in accordance with the individual's needs and goals.

This position serves as a key resource and subject-matter expert for UM practices, providing consultation, education, coaching, and training to UM staff and the provider network. This position also contributes to organizational initiatives, interdisciplinary workgroups, accreditation activities, and continuous quality improvement.

Essential Functions

  • Provide administrative and supervisory oversight for all functions performed by the Utilization Management (UM) Clinical Analysts and ensure the team operates in accordance with organizational standards, regulatory requirements, and established policies and procedures. 
  • Provide leadership, direction, coaching, teaching, facilitation, coordination, problem-solving, and conflict resolution to UM staff.
  • Monitors and evaluates the quality, consistency, and timeliness of authorization decisions, and other utilization management reviews conducted by the team. 
  • Demonstrates an applied commitment to the values as well as knowledge and skills in person served-oriented practices as well as innovations in support, service, treatment, and care practices.
  • Assures adequate supervision/evaluation and performance management processes for all assigned staff members and delegate responsibilities to ensure adherence to clinical criteria, business rules, regulatory requirements, and organization policies.
  • Ensures effective orientation, onboarding, and training for new employees and supports ongoing competency development and inter-rater reliability activities for UM staff. 
  • Manage reports and data for audits and complete audit preparation, oversight to auditing processes, and manage audit process improvements.
  • Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.
  • Conducts and/or oversees prospective, concurrent, and retrospective utilization reviews to evaluate the clinical appropriateness, medical necessity, and effective use of services. 
  • Conducts prospective reviews for service authorizations as identified by OCHN and performs concurrent clinical case reviews as requested.
  • Conducts retrospective reviews of service provision to determine whether services were delivered in the appropriate amount, scope, and duration to reasonably achieve the goals identified in the Individualized Plan of Service (IPOS). 
  • Provide utilization management support/coaching/training to OCHN’s provider network, as needed. 
  • Develops, analyzes, and interprets utilization management data and performance metrics. Prepares reports and makes recommendations for corrective action, process improvement, and recognition of exemplary practices.
  • Participates in workgroups and committees with other OCHN Teams, such as involvement in Clinical, Quality Management, Finance, etc.
  • Supervise, develop, implement, and maintain clinical policies, procedures, and protocols related to UM/UR.
  • Provides leadership and guidance to UM Analysts and collaborates with providers and hospitals regarding performance monitoring, high-risk cases, clinical audits, chart reviews, acute care utilization, care coordination, and discharge planning.
  • Participates in and represents the UM Department in management-level meetings and contributes to the development, implementation, monitoring, and evaluation of departmental goals and objectives.
  • Participates in the development, implementation, and monitoring of policies, procedures, and practices required to maintain compliance with applicable regulatory and accrediting bodies, such as NCQA and HSAG.
  • Supports and consults with the UM team and Due Process Coordinator regarding due process concerns, adverse determinations, appeals, and related issues.
  • Facilitates Inter-Rater Reliability (IRR) testing for the UM/UR department to promote consistency, accuracy, and reliability in utilization management decision-making and processes.
  • Oversees and facilitates the Over- and Under-Utilization data analysis workgroup and coordinates follow-up activities as appropriate. 
  • Maintains knowledge of mandated timelines and requirements related to service authorizations, adverse determinations, denials, and appeals established by MDHHS, NCQA, and other applicable regulatory or accrediting entities. 
  • 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 other duties as 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)
  • CADC, CAADC, or Development Plan preferred.
  • 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.
  • Experience in a supervisory/leadership role.
  • Experience with NCQA, MDHHS, HSAG, and/or accreditation and regulatory compliance activities.
  • Experience with utilization of 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. 
  • Preference for knowledge of the PIHP responsibilities for utilization management.
  • Managed Care and Utilization Management Principles

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.

In addition, the following are preferred competencies:

  • Demonstrated experience in quality assurance and quality monitoring
  • Demonstrated experience in the application of medical necessity
  • Demonstrated experience in data analysis and outcome measurement
  • Demonstrated understanding of the application and outcome measurement of Evidence Based Practices.

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, 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.
  • 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.