Utilization Management Clinical Analyst HYBRID (PCN 1534)

Essential Functions

Apply advanced clinical expertise, behavioral health best practices, medical necessity criteria, Medicaid and PIHP requirements, regulatory standards, and organizational policies to determine the clinical appropriateness of behavioral health and intellectual/developmental disability service authorization requests.

Independently perform comprehensive medical necessity reviews of service authorization requests by analyzing complex clinical information, assessments, treatment plans, and supporting documentation to determine the appropriate amount, scope, duration, intensity, and level of care needed to meet assessed needs, ensuring decisions are clinically sound, timely, well-documented, and consistent with person-centered planning principles and applicable benefit requirements.

Ensure authorization decisions comply with applicable federal and state regulations, Medicaid Provider Manual requirements, PIHP contractual obligations, parity requirements, evidence-based clinical guidelines, and organizational policies and procedures.

Complete retrospective utilization reviews to evaluate whether services provided were medically necessary, clinically appropriate, adequately documented, and delivered in the appropriate amount, scope, duration, and intensity to achieve the goals identified in the Individualized Plan of Service (IPOS).

Participate in the development, validation, implementation, and continuous improvement of utilization management policies, clinical protocols, decision-support tools, audit processes, and workflow enhancements.

Collaborate with internal clinical teams, provider organizations, and community partners to facilitate effective care coordination, timely communication, discharge planning, and continuity of care.

Participate in interdisciplinary committees, quality improvement initiatives, utilization management workgroups, and external stakeholders to support system-wide clinical quality and compliance.

Monitor and analyze utilization patterns, service trends, and authorization data to identify opportunities for quality improvement, ensure appropriate utilization, support regulatory compliance, and inform utilization management practices.

Maintain current knowledge of behavioral health standards of care and state and federal policy and regulations.

Perform other duties and special projects as assigned.

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)