Clinical Specialist – Utilization Management

This is a fully remote position, open to applicants in Michigan.

📋 Description

• Conduct utilization management and service reviews for individuals served by DWIHN.

• Offer clinical expertise and guidance to care coordination teams.

• Facilitate integrated care delivery involving providers, health homes, beneficiaries, families, community agencies, and services.

• Coordinate and review complex care arrangements to ensure quality, efficiency, and optimal outcomes.

• Encourage the integration of medical and behavioral healthcare through effective communication and collaboration with providers.

• Perform electronic case reviews and authorize treatment plans based on medical necessity criteria.

• Assess clinical appropriateness and oversee provider treatment plans for quality and effectiveness.

• Determine funding eligibility and apply criteria for priority status regarding placement.

• Identify suitable levels of care and initiate referrals to designated providers.

• Provide reauthorization for services related to substance use disorders, mental health, and co-occurring conditions.

• Manage behavioral health utilization for psychiatric inpatient, detoxification, residential authorizations, and care management processes.

• Support providers with client information, appropriate referrals, and assistance with treatment-service barriers.

• Ensure proper follow-up and aftercare plans while promoting continuity of care.

• Monitor client compliance with services and suggest alternative and innovative care plans.

• Engage in program enhancements and contribute to the Quality Improvement program.

• Collect, document, and analyze data to achieve desired outcomes.

• Advocate for members to ensure their treatment needs are fulfilled.

• Identify and evaluate enrollees, develop and manage treatment plans, and facilitate complex care arrangements.

• Conduct initial and ongoing assessments of enrollees’ behavioral and physical clinical status and functioning.

• Communicate with medical and behavioral providers regarding treatment planning and clinical/psychosocial needs.

• Involve enrollees and providers in setting both short- and long-term goals.

• Coordinate care for individuals with highly complex needs, including transitions across various levels of care and severe medical or behavioral conditions.

• Review requests for authorization or reauthorization of medically appropriate services and length of stay.

• Manage client care using the MHWIN system.

• Maintain the reauthorization database with up-to-date treatment statuses.

• Track and monitor cost factors related to service utilization, treatment activities, access, and placement criteria.

• Conduct daily utilization reviews of client cases involving SMI, SUD, and COD.

• Input data and reports into both written formats and electronic databases.

• Ensure provider compliance with Federal, State, and Medicaid admission requirements.

• Travel to various sites across Wayne County and throughout the State of Michigan as necessary.

• Perform additional related duties as assigned.

⛳️ Requirements

• Master’s Degree from an accredited college or university in Human Services, Social Services, Nursing, Public Health, Public Administration, Healthcare Administration, Health Management, or a related field; a Bachelor’s Degree is acceptable for Nursing.

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

• A minimum of two (2) years of experience in clinical case management within a behavioral healthcare or mental health environment.

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

• Valid State of Michigan Driver’s License with a safe and satisfactory driving record.

• Familiarity with DWIHN policies, procedures, and practices.

• Knowledge of the DWIHN provider network and community resources.

• Understanding of the Michigan Mental Health Code.

• Awareness of MDHHS policies, rules, regulations, and procedures.

• Knowledge of relevant Federal policies, rules, regulations, and procedures.

• Proficiency in MHWIN.

• Understanding of utilization management and managed care principles and practices.

• Familiarity with ICD-10, CPT, DSM-V, or the most current diagnostic edition.

• Knowledge of clinical care processes, including screening, assessment, treatment planning, case management, and ongoing care.

• Awareness of the adult continuum of care for I/DD, SMI, and co-occurring disorder disability designations.

• Understanding of compliance standards and Medical Necessity Criteria for Behavioral Health Services.

• Strong skills in assessment, organization, planning, problem-solving, decision-making, interpersonal communication, implementation, and written communication.

• Proficient in computer applications such as Word, Excel, Access, PowerPoint, Outlook, and Teams.

• Ability to communicate effectively both orally and in writing.

• Capability to work collaboratively with others from diverse ethnic, linguistic, cultural, economic, and social backgrounds.

• Sound judgment and reasoning abilities.

• Proof of full COVID-19 vaccination as a condition of employment, subject to legally required accommodations or exemptions.

🏝️ Benefits

• Possibility of remote work with supervisory approval; currently primarily remote.

• Medical or religious accommodations and other legally required COVID-19 vaccination exemptions.

• Equal Opportunity Employer.