Oakland Community Health Network·Troy, Michigan
Conducts prospective, concurrent, and retrospective reviews of behavioral health service authorizations to ensure medical necessity and efficient use of psychiatric services. Collaborates with providers and interdisciplinary teams to support continuity of care and regulatory compliance according to Michigan Medicaid standards.
Utilization Review Analyst conducts prospective, concurrent, and retrospective reviews of service authorizations, ensuring the appropriate, effective, and efficient use of acute psychiatric inpatient and state facility services. Reviews clinical documentation to determine medical necessity and authorize service in accordance with Michigan Medicaid Provider Manual requirements, organizational policies, and applicable regulatory standards. Collaborates with network providers, hospitals, and interdisciplinary teams to support timely authorization decisions, continuity of care, and appropriate transitions across the behavioral health continuum while maintaining accurate clinical documentation and regulatory compliance.
Essential Functions
Conduct concurrent utilization reviews of behavioral health services for acute psychiatric hospitals, state psychiatric facilities, and other levels of care to determine medical necessity, appropriateness of admission, continued stay, and discharge in accordance with Michigan Medicaid Provider Manual requirements and applicable regulatory requirements.
Review and analyze clinical documentation using established medical necessity criteria, clinical guidelines, contractual requirements, and reimbursement policies to make authorization determinations for inpatient behavioral health services.
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.
Apply evidence-based utilization management criteria and clinical protocols to establish continued stay review intervals and determine authorization status.
Document clinical reviews, authorization decisions, and supporting rationale accurately and within required timeframes in accordance with organizational, contractual, and accreditation standards.
Utilize clinical knowledge of behavioral health services, Michigan Medicaid Provider Manual requirements and organizational policies to ensure appropriate utilization of services and compliance with applicable regulations.
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 additional duties and special projects assigned.
Job Requirements and Qualifications
• Master's degree in mental health field.
Must maintain Child Diagnostic and Treatment Professional (CDTP) eligibility, including 24 hours of annual child-specific training.
• 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.
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)
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.
Market context
Behavioral health openings in Michigan often draw steady interest because employers need independently licensed clinicians who can provide consistent weekly availability. For this LMSW role, competition may center on licensure status, schedule flexibility, and readiness to meet a 25-session, 30-hour weekly commitment. Review the AI-summarized requirements and benefits here to save time versus reading the full posting, then confirm your Michigan licensure and availability before applying.
