Clinical Specialist Utilization Management

About this position Pay Grade: 8

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.

• Provides Utilization Management and review of services to persons served by DWIHN.
• Provides clinical expertise and consultation for care coordination teams.
• Facilitates an integrated approach to care delivery with providers, health homes, beneficiaries, their families, and community agencies and services.
• Reviews the management and coordination complex care arrangements to ensure quality and efficiency of care and achieve the best possible outcomes.
• Promotes the integration of medical and behavioral health care by increasing communication and collaboration between health care providers.
• Authorizes treatment plans.
• Provides consultations utilizing medical necessity criteria.
• Evaluates clinical appropriateness.
• Monitors provider treatment plans to ensure quality and effectiveness of service.
• Applies priority status criteria for placement.
• Determines appropriate levels of care for referrals.
• Initiates referrals to selected providers.
• Provides re-authorization of SUD/Mental Health/co-occurring services.
• Provides behavioral health utilization management services for the treatment provider network for psychiatric inpatient, detox, residential authorizations and care management processes.
• Assists providers when needed with additional client information to assure appropriate referrals and remove barriers for treatment services.
• Ensures follow-up and aftercare plans are appropriate for individuals who were admitted for treatment and assists them with a continuum of care.
• Monitors client’s compliance with services.
• Proposes alternative and creative Care Plans.
• Participates in program enhancements and the QI program.
• Performs data gathering, documentation and analysis for desired outcomes.
• Advocates for members to ensure treatment needs are met.
• Follows 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. .
• Performs initial and ongoing review of enrollee’s clinical status and functioning (behavioral and physical).
• Communicates with medical and behavioral providers regarding treatment planning.
• Communicates with medical and behavioral providers regarding clinical and psychosocial needs.
• Engages the enrollee and providers in identifying short-term and long‑term goals consistent with the clinical situation and enrollee strengths.
• Arranges care for highly complex needs such as transitions across levels of care, severe medical and behavioral conditions.
• Reviews requests for authorizing/reauthorizing medically appropriate services and length of stay
• Manages client care through the MHWIN system.
• Ensures that the reauthorizations database is continuously updated and reflects the current status of individuals in treatment.
• Tracks and monitors cost factors relative to service utilization, treatment activities, and other access and placement criteria.
• Conducts utilization reviews of SMI, SUD/COD client cases daily.
• Enters data and reports into written formats and electronic databases.
• Monitors provider services for adherence to priority Federal, State and Medicaid admission requirements.
• Performs related duties as assigned.
• 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…