Manager of UM - UR

Job Summary

The Manager of Utilization Management (UM) is responsible for day-to-day management and oversight of utilization management activities to ensure the appropriate, efficient, and cost-effective delivery of services throughout the Service Network. This position provides operational leadership for utilization review processes, utilization monitoring, staff supervision, provider collaboration, and performance improvement initiatives. The Manager ensures compliance with applicable federal and state regulations, contractual requirements, accreditation standards, and organizational policies while supporting organizational goals related to quality, access, service utilization, and cost containment. The Manager works collaboratively with internal departments, providers, and community stakeholders to optimize service utilization, identify trends, implement corrective actions, and improve outcomes for persons served.

Essential Functions

• Supervises and provides leadership, coaching, performance management, and professional development for Utilization Management staff.
• Oversees daily Utilization Management operations, ensuring compliance with organizational policies, provider contracts, accreditation standards, and state and federal requirements.
• Manages service authorization, utilization review, and monitoring activities to ensure services are clinically appropriate, cost-effective, and consistent with person-centered plans of care.
• Analyzes utilization, access, quality, and cost data; identifies trends; develops recommendations; and implements performance improvement initiatives.
• Monitors Utilization Management performance indicators and ensures corrective actions are implemented when established targets are not achieved.
• Develops and maintains Utilization Management policies, procedures, monitoring tools, and operational processes in collaboration with organizational leadership.
• Prepares and presents utilization reports, analyses, and recommendations for leadership, committees, and other stakeholders.
• Collaborates with providers to address utilization concerns, improve performance, and implement corrective action or improvement plans, as needed.
• Coordinates provider and staff education related to utilization management requirements, processes, and best practices.
• Supports provider issue resolution, utilization-related complaints, disputes, and appeals in collaboration with internal and external stakeholders.
• Collaborates with Clinical, Quality, Finance, Compliance, Information Technology, and other departments to support organizational initiatives and strategic priorities.
• Assists with audits, reviews, accreditation activities, and regulatory reporting requirements.
• Participates in organizational committees, workgroups, and special projects related to utilization management and service network performance.
• Performs other duties as assigned.

Job Requirements and Qualifications

Education:

• Master's degree in mental health field.

Training Requirements (licenses, programs, or certificates):

• State of Michigan license, certification and / or registration as, Psychologist (LLP, LP), Social Worker (LMSW), Counselor (LPC), Marriage and Family Therapist (LMFT) or Nurse (RN).
• For children’s services - maintain/attain 24 hours annually of child-specific training (Child Diagnostic and Treatment Professional).

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.

Knowledge Requirements:

• Knowledge of the Michigan Mental Health Code.
• Strong understanding of Medicaid rules, regulations, and requirements outlined in the Michigan Medicaid Provider Manual.
• Applies knowledge of managed care principles and utilization management practices to support compliance, effective service delivery, and appropriate resource utilization.
• Community Mental Health service delivery system CMHSP & PIHPs
• NCQA (National Committee for Quality Assurance) and HSAG (Health Services Advisory Group) standards (UM).
• Extensive knowledge and understanding of the OHCN network, including substance use disorder services, supports, and the continuum of care.

Job Specific Competencies/Skills:

• Demonstrated effective interpersonal skills.
• Demonstrated ability to work effectively in a team environment.
• Demonstrated effective written and oral communication skills.
• Demonstrated effective computer skills.

In addition, the following are preferred competencies:

• Demonstrated experience in quality assurance and quality monitoring.
• Demonstrated experience in the application of medical necessities.
• 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):

• 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 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.