Utilization Review Supervisor (PCN 1547)

Oakland Community Health Network -
Troy, MI

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Job Details

Full-time
$70,298 - $87,873 a year

Qualifications

Experience working with individuals with cognitive disabilities
Master's degree
Medicaid health insurance
Intellectual disabilities support
Working with individuals with mental health conditions
Medicaid regulations
Medicaid
Experience working with individuals with substance use disorders
Experience working with individuals with intellectual disabilities
Stakeholder relationship building

Full Job Description

Job Summary

The Supervisor of Utilization Review (UR) oversees the development, implementation, and maintenance of Utilization Review (UR) clinical policies, procedures, and protocols. This position supervises UR Analysts and Acute Care Authorization Analysts and provides clinical and operational oversight for crisis authorizations, concurrent reviews, acute care utilization, high-risk cases, care coordination, and discharge planning.

The UR Supervisor collaborates with providers, hospitals, state facilities, community partners, and internal OCHN departments to ensure appropriate, effective, and efficient use of resources. Responsibilities include supporting NCQA compliance, MDHHS reporting, appeals and due process requirements, case consultation, quality improvement initiatives, and data analysis. The position also participates in management meetings, workgroups, and strategic initiatives while ensuring compliance with regulatory, accreditation, and organizational standards.

Essential Functions

Supervise and evaluate Utilization Review (UR) and Acute Care Authorization staff to ensure adherence to clinical criteria, business rules, regulatory requirements, and organizational policies.
Provide leadership, oversight, and support for Acute Care Authorization staff responsible for 24/7 operations, ensuring continuity of services, timely decision-making, and compliance with organizational and regulatory requirements.

Oversee reviews of admissions, continued stays, and lengths of stay to ensure clinical appropriateness and compliance with reimbursement, accreditation, and regulatory standards.
Provide clinical oversight, advocacy, and authorization support for individuals requiring acute care, State Facility placement, enhanced staffing, or higher levels of care.
Collaborate with network providers, acute care hospitals, state psychiatric facilities, and interdisciplinary treatment teams to facilitate utilization review activities, continuity of care, and effective discharge planning.
Ensure timely and comprehensive review of clinical information, including accurate documentation of decisions and supporting rationale.
Lead onboarding, training, coaching, and inter-rater reliability activities, including use of the MCG Parity Tool.
Develop, implement, and maintain utilization of review policies, procedures, protocols, and quality improvement initiatives, including those related to NCQA and HSAG requirements.
Monitor compliance with authorization, denial, appeal, and reporting requirements established by MDHHS, NCQA, and other regulatory agencies.
Analyze, monitor, and report utilization data, including hospital census, admissions, discharges, lengths of stay, recidivism, and staff performance trends to identify improvement opportunities.
Participate in organizational committees, workgroups, and initiatives.
Represent the Utilization Review department in meetings and special projects assigned by leadership.
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)
    Must maintain Child Diagnostic and Treatment Professional (CDTP) eligibility, including 24 hours of annual child-specific training.

Experience Requirements:

Minimum of five (5) years relevant experience providing services to Adults with Mental Illness, Intellectual or Developmental Disabilities, Substance Use Disorder and/or children with serious emotional disturbance or intellectual or Development 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 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 Practice.

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, 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.

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