Utilization Management Clinical Analyst HYBRID; PCN

Full Time Professional Troy, Troy, MI, US

Salary Range: $56,165.00 To $70,206.00 Annually

The Utilization Management Clinical Analyst conducts prospective reviews of authorization requests to determine medical necessity and clinical appropriateness of behavioral health services in accordance with Level of Care Need, Medicaid guidelines, MDHHS requirements and the Michigan Mental Health Code. This position applies clinical expertise and evidence-based criteria to support timely utilization management decisions, promote appropriate resource utilization, and ensures quality, person-centered care through collaboration with providers and internal stakeholders.

• 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 reviewsto 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 work groups, 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.

• Master’s degree in the mental health field or relevant discipline required.

• Possession and maintenance of a current, unrestricted State of Michigan professional license in one of the following disciplines:
• Licensed Psychologist (LLP or LP)
• Licensed Master's Social Worker (LMSW)
• Licensed Professional Counselor (LPC)
• Licensed Marriage and Family Therapist (LMFT)
• Registered Nurse (RN)
• 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.

• Experience with in a Community Mental Health Services Program (CMHSP), Prepaid Inpatient Health Plan (PIHP), Managed Care Organization (MCO), hospital, or behavioral health setting.
• Preference for CADC or CAADC credentials.

• Michigan Mental Health Code.
• Medicaid guidelines, regulations, and Michigan Medicaid Provider Manual.
• Manage Care Principles and Utilization Management.
• Preference for knowledge of the PIHP responsibilities for utilization management.