Clinical Specialist Utilization Management

About this position

Under the general supervision of the Director of Utilization Management for the Detroit Wayne Integrated Health Network (DWIHN), Clinical Specialists – Utilization Management are responsible for providing utilization management and review of services to consumers.

Principal Duties and Responsibilities

• Provide utilization management and review of services to persons served by DWIHN.
• Provide clinical expertise and consultation for care coordination teams.
• Facilitate an integrated approach to care delivery with providers, health homes, beneficiaries, their families, and community agencies and services.
• Review management and coordination of complex care arrangements to ensure quality and efficiency of care and achieve the best possible outcomes.
• Promote integration of medical and behavioral health care by increasing communication and collaboration between health care providers.
• Conduct electronic case reviews.
• Authorize treatment plans.
• Provide consultations utilizing medical necessity criteria.
• Evaluate clinical appropriateness.
• Monitor provider treatment plans to ensure quality and effectiveness of service.
• Establish funding eligibility.
• Apply priority status criteria for placement.
• Determine appropriate levels of care for referrals.
• Initiate referrals to selected providers.
• Provide re‑authorization of SUD/Mental Health/co‑occurring services.
• Offer behavioral health utilization management services for the treatment provider network for psychiatric inpatient, detox, residential authorizations and care management processes.
• Assist providers when needed with additional client information to assure appropriate referrals and remove barriers for treatment services.
• Ensure follow‑up and aftercare plans are appropriate for individuals admitted for treatment and assist them with a continuum of care.
• Monitor client’s compliance with services.
• Propose alternative and creative care plans.
• Participate in program enhancements and the QI program.
• Perform data gathering, documentation and analysis for desired outcomes.
• Advocate for members to ensure treatment needs are met.
• Follow guidelines of the integrated care case management program with respect to identifying and assessing enrollees, developing and managing the treatment plans, and facilitating complex care arrangements.
• Perform initial and ongoing review of enrollee’s clinical status and functioning (behavioral and physical).
• Communicate with medical and behavioral providers regarding treatment planning.
• Communicate with medical and behavioral providers regarding clinical and psychosocial needs.
• Engage the enrollee and providers in identifying short‑term and long‑term goals consistent with the clinical situation and enrollee strengths.
• Arrange care for highly complex needs such as transitions across levels of care, severe medical and behavioral conditions.
• Review requests for authorizing/reauthorizing medically appropriate services and length of stay.
• Manage client care through the MHWIN system.
• Ensure the reauthorization database is continuously updated and reflects the current status of individuals in treatment.
• Track and monitor cost factors relative to service utilization, treatment activities, and other access and placement criteria.
• Conduct utilization reviews of SMI, SUD/COD client cases daily.
• Enter data and reports into written formats and electronic databases.
• Monitor provider services for adherence to priority Federal, State and Medicaid admission requirements.
• Perform related duties as assigned.

Knowledge, Skills and Abilities (KSA’s)

• Knowledge of DWIHN policies, procedures and practices.
• Knowledge of the DWIHN provider network and community resources.
• Knowledge of the Michigan Mental Health Code.
• Knowledge of MDHHS policies, rules, regulations and procedures.
• Knowledge of Federal policies, rules, regulations and procedures as they relate to DWIHN.
• Knowledge of MHWIN.
• Knowledge of utilization management practices and principles.
• Knowledge of managed care practices and principles.
• Knowledge of ICD‑10, CPT, DSM‑V or the most current diagnostic edition.
• Knowledge of the clinical care process (screening, assessment, treatment planning, case management, and continuing care).
• Knowledge of the adult continuum of care for all disability designations (I/DD, SMI, Co‑Occurring Disorder).
• Knowledge of compliance standards.
• Knowledge of medical necessity criteria for behavioral health services.
• Knowledge of documents/regulations that govern the provision of mental health services, e.g., Medicaid Manual Mental Health and Substance Abuse Chapter III, State Plan for Medicaid, Michigan Department of Health and Human Services Quality Plan, BBA requirements and the Mental Health Code.
• Assessment skills.
• Organizational skills.
• Planning skills.
• Problem‑solving skills.
• Decision‑making skills.
• Interpersonal skills.
• Communication skills.
• Implementation skills.
• Written communication skills.
• Computer skills (Word, Excel, Access, PowerPoint, Outlook, Teams).
• Teamwork skills.
• Ability to communicate orally.
• Ability to communicate in writing.
• Ability to work effectively with others.
• Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.
• Judgement/Reasoning ability.

Required Education

A Master’s Degree from a recognized college or university in Human Services, Social Services, Nursing (a Bachelor’s Degree will be accepted), Public Health, Public Administration, Healthcare Administration, Health Management, or a related field.

Required Experience

Four (4) years of professional experience in behavioral healthcare or a mental health setting, with at least two (2) years in clinical case management within a behavioral healthcare or mental health setting.

Required Licenses

• Valid State of Michigan clinical licensure: RN, LMSW, LMHC, LPC, LLP or PhD.
• Valid State of Michigan Driver’s License with a safe and acceptable driving record.

Working Conditions

Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval.

Proof of full vaccination for COVID‑19 is required as a condition of employment. Medical or religious accommodations or other exemptions required by law will be approved when properly supported.

The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer.