Clinical Specialist Utilization Management

DETROIT WAYNE Integrated HEALTH Network; Detroit (MI); Remote; USD 75,000 - 110,000; Full time

Job summary

Detroit Wayne Integrated Health Network (DWIHN) seeks an experienced Clinical Specialist – Utilization Management to oversee UM reviews and care coordination across a network of providers in Wayne County and Michigan.

Reporting to the Director of Utilization Management, the role emphasizes medical necessity criteria, treatment plan authorization, care level determinations, and collaboration with health homes and community partners to ensure high-quality, coordinated behavioral health services.

Qualifications

• Master’s degree in a relevant field is required.
• Four years of professional experience in behavioral healthcare.
• A valid Michigan clinical license (RN, LMSW, LMHC, LPC, LLP or PhD) required.

Responsibilities

• Provides utilization management and review of services for DWIHN clients.
• Offers clinical expertise and consultation for care coordination teams.
• Facilitates integrated care delivery with providers and community partners.
• Authorizes treatment plans and applies medical necessity criteria.
• Monitors and evaluates provider treatment plans for quality and effectiveness.
• Performs data gathering and analysis for outcomes and reporting.

Skills

Utilization management

Care coordination

Clinical consultation

Medial necessity criteria

Quality improvement

Education

Master’s degree in Human Services / Social Services / Nursing / Public Health / Healthcare Administration

Job description

About this position

Pay Grade: 8

Under the general supervision of the Director of Utilization Management for the Detroit Wayne Integrated Health Network (DWIHN), Clinical Specialists – Utilization Management are responsible for providing utilization management and review of services to consumers.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Provides Utilization Management and review of services to persons served by DWIHN.
• Provides clinical expertise and consultation for care coordination teams.
• Facilitates an integrated approach to care delivery with providers, health homes, beneficiaries, their families, and community agencies and services.
• Reviews the management and coordination complex care arrangements to ensure quality and efficiency of care and achieve the best possible outcomes.
• Promotes the integration of medical and behavioral health care by increasing communication and collaboration between health care providers.
• Authorizes treatment plans.
• Provides consultations utilizing medical necessity criteria.
• Evaluates clinical appropriateness.
• Monitors provider treatment plans to ensure quality and effectiveness of service.
• Applies priority status criteria for placement.
• Determines appropriate levels of care for referrals.
• Initiates referrals to selected providers.
• Provides re-authorization of SUD/Mental Health/co-occurring services.
• Provides behavioral health utilization management services for the treatment provider network for psychiatric inpatient, detox, residential authorizations and care management processes.
• Assists providers when needed with additional client information to assure appropriate referrals and remove barriers for treatment services.
• Ensures follow-up and aftercare plans are appropriate for individuals who were admitted for treatment and assists them with a continuum of care.
• Monitors client’s compliance with services.
• Proposes alternative and creative Care Plans.
• Participates in program enhancements and the QI program.
• Performs data gathering, documentation and analysis for desired outcomes.
• Advocates for members to ensure treatment needs are met.
• Follows guidelines of the integrated care case management program with respect to identifying and assessing enrollees, developing and managing the treatment plans, and facilitating complex care arrangements. .
• Performs initial and ongoing review of enrollee’s clinical status and functioning (behavioral and physical).
• Communicates with medical and behavioral providers regarding treatment planning.
• Communicates with medical and behavioral providers regarding clinical and psychosocial needs.
• Engages the enrollee and providers in identifying short-term and long‑term goals consistent with the clinical situation and enrollee strengths.
• Arranges care for highly complex needs such as transitions across levels of care, severe medical and behavioral conditions.
• Reviews requests for authorizing/reauthorizing medically appropriate services and length of stay
• Manages client care through the MHWIN system.
• Ensures that the reauthorizations database is continuously updated and reflects the current status of individuals in treatment.
• Tracks and monitors cost factors relative to service utilization, treatment activities, and other access and placement criteria.
• Conducts utilization reviews of SMI, SUD/COD client cases daily.
• Enters data and reports into written formats and electronic databases.
• Monitors provider services for adherence to priority Federal, State and Medicaid admission requirements.
• Performs related duties as assigned.
• Knowledge of DWIHN policies, procedures and practices.
• Knowledge of the DWIHN provider network and community resources.
• Knowledge of the Michigan Mental Health Code.
• Knowledge of MDHHS policies, rules, regulations and procedures.
• Knowledge of Federal policies, rules, regulations and procedures as it relates to DWIHN.
• Knowledge of MHWIN.
• Knowledge of Utilization Management practices and principles.
• Knowledge of managed care practices and principles.
• Knowledge ICD 10, CPT, DSM V or most current diagnostic edition.
• Knowledge of the clinical care process (screening, assessment, treatment planning, case management, and continuing care).
• Knowledge of the Adult continuum of care for all disability designations (I/DD, SMI, Co‑Occurring Disorder).
• Knowledge of compliance standards.
• Knowledge of Medical Necessity Criteria for Behavioral Health Services.
• Knowledge of documents / regulations that govern the provision of mental health services, e.g., Medicaid Manual Mental Health and Substance Abuse Chapter III, State Plan for Medicaid, Michigan Department of Health and Human Services Quality Plan, BBA requirements and the Mental Health Code.
• Ability to work effectively with others.
• Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.
• Judgement/Reasoning ability

REQUIRED EDUCATION:

A Master’s Degree from a recognized college or university in the Human Services, the Social Services,Nursing (a Bachelor’s Degree will be accepted),Public Health, Public Administration,Healthcare Administration, Health Management,or a related field.

REQUIRED EXPERIENCE:

Four (4) years of professional experience in behavioral healthcare or mental health setting.

Experience must in include at least two (2) years in the following:

• Experience performing clinical case management in a behavioral healthcare or mental health setting.

REQUIRED LICENSE(S).

A Valid State of Michigan clinical licensure: RN, LMSW , LMHC, LPC, LLP or PhD.

A valid State of Michigan Driver’s License with a safe and acceptable driving record.

WORKING CONDITIONS

Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval.

Clinical Specialist Utilization Management

Pay Grade: 8

Under the general supervision of the Director of Utilization Management for the Detroit Wayne Integrated Health Network (DWIHN), Clinical Specialists – Utilization Management are responsible for providing utilization management and review of services to consumers.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Provides Utilization Management and review of services to persons served by DWIHN.
• Provides clinical expertise and consultation for care coordination teams.
• Facilitates an integrated approach to care delivery with providers, health homes, beneficiaries, their families, and community agencies and services.
• Reviews the management and coordination complex care arrangements to ensure quality and efficiency of care and achieve the best possible outcomes.
• Promotes the integration of medical and behavioral health care by increasing communication and collaboration between health care providers.
• Conducts electronic case reviews.
• Authorizes treatment plans.
• Provides consultations utilizing medical necessity criteria.
• Evaluates clinical appropriateness.
• Monitors provider treatment plans to ensure quality and effectiveness of service.
• Establishes funding eligibility.
• Applies priority status criteria for placement.
• Determines appropriate levels of care for referrals.
• Initiates referrals to selected providers.
• Provides re‑authorization of SUD/Mental Health/co‑occurring services.
• Provides behavioral health utilization management services for the treatment provider network for psychiatric inpatient, detox, residential authorizations and care management processes.
• Assists providers when needed with additional client information to assure appropriate referrals and remove barriers for treatment services.
• Ensures follow‑up and aftercare plans are appropriate for individuals who were admitted for treatment and assists them with a continuum of care.
• Monitors client’s compliance with services.
• Proposes alternative and creative Care Plans.
• Participates in program enhancements and the QI program.
• Performs data gathering, documentation and analysis for desired outcomes.
• Advocates for members to ensure treatment needs are met.
• Follows guidelines of the integrated care case management program with respect to identifying and assessing enrollees, developing and managing the treatment plans, and facilitating complex care arrangements. .
• Performs initial and ongoing review of enrollee’s clinical status and functioning (behavioral and physical).
• Communicates with medical and behavioral providers regarding treatment planning.
• Communicates with medical and behavioral providers regarding clinical and psychosocial needs.
• Engages the enrollee and providers in identifying short‑term and long‑term goals consistent with the clinical situation and enrollee strengths.
• Arranges care for highly complex needs such as transitions across levels of care, severe medical and behavioral conditions.
• Reviews requests for authorizing/reauthorizing medically appropriate services and length of stay
• Manages client care through the MHWIN system.
• Ensures that the reauthorizations database is continuously updated and reflects the current status of individuals in treatment.
• Tracks and monitors cost factors relative to service utilization, treatment activities, and other access and placement criteria.
• Conducts utilization reviews of SMI, SUD/COD client cases daily.
• Enters data and reports into written formats and electronic databases.
• Monitors provider services for adherence to priority Federal, State and Medicaid admission requirements.
• Performs related duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES (KSA’S):

• Knowledge of DWIHN policies, procedures and practices.
• Knowledge of the DWIHN provider network and community resources.
• Knowledge of the Michigan Mental Health Code.
• Knowledge of MDHHS policies, rules, regulations and procedures.
• Knowledge of Federal policies, rules, regulations and procedures as it relates