Utilization Management Manager

Essential Functions

The UM Manager position is an administrative position with responsibility in providing regional oversight of clinical service utilization and delivery of behavioral health services across the region respective to the Utilization Management Program Plan, regional clinical practice guidelines, Michigan Medicaid Provider Manual and MDHHS contract requirements.

An employee at this level will be involved in the following duties which are typical, not inclusive of all tasks to be performed:

· Member of Region 10 Utilization Management Committee

· Assists with developing and implementing regional Utilization Management Program Plan

· Assists with the development and generation of strategies, functions, and UM/UR monitoring/evaluation reports supporting UM Program Plan implementation

· Directs regional Utilization Review across the CMHSP and SUD provider networks, including case finding, case record review, protocol updates, and quarterly and end of year reports.

· Serves as member on Region 10 Improving Practices Leadership Team, Region 10 PIHP Credentialing and Privileging Committee, and other work groups as required

· Assists in the development and periodic evaluation of regional clinical practice guidelines

· Facilitates and supports provider network implementation and sustainment activities pertaining to MDHHS evidence-based practices and practice standards and guidance documents

· Provides technical guidance in clinical issues related to regional privileging and credentialing policy standards

· Provides technical guidance in clinical issues related to regional Grievance and Appeal policy standards

· Reviews UMC quarterly reports from CMHSPs (Behavioral Treatment Plan services, emergency use of physical management, Adverse Benefit Determination, and Customer Involvement, Wellness / Healthy Communities)

· Provides periodic reports to the Region 10 PIHP Sentinel Events Review Committee (Critical Incidents, Sentinel Events, Risk Events)

· Serves as backup to the CCO on the state-wide UM Directors Group

Minimum Qualifications (An employee must have the following credentials, training, and experience)

· Master’s Degree in Social Work, Counseling, or Psychology

· Current relevant State of Michigan Professional Licensure

· 5 years of experience working in public behavioral health system

· Demonstrated knowledge of Mental Health treatment procedures applicable to public mental health populations

· Demonstrated knowledge of current and best practices within behavioral health services

· Demonstration of proficiency and experience working in an Electronic Health Record System

· Demonstrated knowledge of State of Michigan Medicaid Provider Manual

· Demonstrated knowledge of MDHHS contract requirements

· Demonstrated ability with Windows and Microsoft Office products

· Valid State of Michigan Driver’s License

· Must have access to transportation

PREFERRED Qualifications

· Doctorate degree in human services related field

· CAADC

· Experience working for Prepaid Inpatient Health Plan

· 5+ years of experience working in the public behavioral health care system

· Meet requirements as QMHP, QMRP or QIDP

· 3+ years of supervisory experience

· Experience working in PowerBI data analytics and reporting