Utilization Management Supervisor

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.

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.
• 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.

Additional Information: 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.