Utilization Review Analyst at Oakland Community Health Network

Troy, Michigan, United States -

Full Time

Start Date

Immediate

Expiry Date

13 Jan, 26

Salary

0.0

Posted On

15 Oct, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Interpersonal Skills, Teamwork, Written Communication, Oral Communication, Computer Skills, Quality Assurance, Data Analysis, Outcome Measurement, Evidence Based Practices, Clinical Knowledge, Utilization Management, Documentation, Discharge Planning, Regulatory Guidelines, Customer Focus, Continuous Learning

Industry

Mental Health Care

Description

Job Summary Promotes appropriate, effective, and efficient use of resources via concurrent reviews of acute care authorizations. The scope of this position includes the review of clinical care and treatment plans by staff in the OCHN provider network, acute care settings and at times, State facilities. Essential Functions Under direction: * Analyzes records to determine legitimacy of admission, treatment, and length of stay in acute care to comply with government and insurance company reimbursement policies analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning treatment and length of stay. * Compares inpatient medical records to established criteria and confers with OCHN provider personnel as well as personnel in acute care and other professional staff to determine legitimacy of treatment and length of stay. * Determines continued stay review dates according to established clinical protocols and diagnostic criteria. * Conducts continued stay reviews and determines continued authorization status. * Coordinates with OCHN and acute care providers to ensure appropriate communication and discharge planning occurs. * Accountable for timely and comprehensive review of clinical data with concise documentation, decisions and rationale. * Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness for acute care authorizations. * Participate in workgroups and committees with other OCHN Teams, such as involvement in Access, Quality Management, or benefits coordination initiatives, etc. * Additional duties as assigned. Job Requirements and Qualifications Education: * Master's degree in mental health field. Training Requirements (licenses, programs, or certificates): * State of Michigan license, certification and / or registration as, Psychologist (LLP, LP), Social Worker (LMSW), Counselor (LPC), Marriage and Family Therapist (LMFT) or Nurse (RN). * For children’s services - maintain/attain 24 hours annually of child-specific training (Child Diagnostic and Treatment Professional). 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. * Preference for experience in the OCHN network. * Knowledge of the Michigan Mental Health Code * Understanding of Medicaid rules and regulations. * Understanding of utilization management * Preference for knowledge of the OCHN Utilization Management Manual and Protocols. Preferred Requirements: * Job Specific Competencies/Skills: * Demonstrated effective interpersonal skills. * Demonstrated ability to work effectively in a team environment * Demonstrated effective written and oral communication skills. * Demonstrated effective computer skills. 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 Practices. 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, on-call 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. * 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.

Responsibilities

The Utilization Review Analyst promotes the effective use of resources through concurrent reviews of acute care authorizations. This includes analyzing clinical care and treatment plans to ensure compliance with reimbursement policies and conducting continued stay reviews.