Clinical Specialist – Utilization Management

🔥 18 hours ago

🚗 Michigan – Remote

🚗 Michigan – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 12%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Detroit Wayne Integrated Health Network

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2013

🏥 Healthcare

🤝 Non-profit

Healthcare • Mental Health • Non-profit

Detroit Wayne Integrated Health Network is a healthcare safety net organization that provides access to comprehensive integrated services aimed at promoting mental health and well-being. The organization offers various programs, including crisis services, support for individuals with mental illness, autism services, and substance use disorder treatment, with a mission to enhance the overall quality of life for its members in Wayne County.

📋 Description

• Provide utilization management and review of services for persons served by DWIHN • Provide clinical expertise and consultation for care coordination teams • Facilitate integrated care delivery with providers, health homes, beneficiaries, families, community agencies, and services • Review and coordinate complex care arrangements to ensure quality, efficiency, and optimal outcomes • Promote integration of medical and behavioral healthcare through provider communication and collaboration • Conduct electronic case reviews and authorize treatment plans using medical necessity criteria • Evaluate clinical appropriateness and monitor provider treatment plans for quality and effectiveness • Establish funding eligibility and apply priority status criteria for placement • Determine appropriate levels of care and initiate referrals to selected providers • Provide reauthorization for substance use disorder, mental health, and co-occurring services • Provide behavioral health utilization management for psychiatric inpatient, detoxification, residential authorizations, and care management processes • Assist providers with client information, appropriate referrals, and treatment-service barriers • Ensure appropriate follow-up and aftercare plans and support continuity of care • Monitor client compliance with services and propose alternative and creative care plans • Participate in program enhancements and the Quality Improvement program • Gather, document, and analyze data for desired outcomes • Advocate for members to ensure treatment needs are met • Identify and assess enrollees, develop and manage treatment plans, and facilitate complex care arrangements • Perform initial and ongoing reviews of enrollees’ behavioral and physical clinical status and functioning • Communicate with medical and behavioral providers regarding treatment planning and clinical/psychosocial needs • Engage enrollees and providers in establishing short- and long-term goals • Arrange care for highly complex needs, including transitions across levels of care and severe medical or behavioral conditions • Review requests for authorization or reauthorization of medically appropriate services and length of stay • Manage client care through the MHWIN system • Maintain the reauthorization database with current treatment status • Track and monitor cost factors related to service utilization, treatment activities, access, and placement criteria • Conduct daily utilization reviews of SMI, SUD, and COD client cases • Enter data and reports into written formats and electronic databases • Monitor provider adherence to Federal, State, and Medicaid admission requirements • Drive to different sites throughout Wayne County and the State of Michigan as needed • Perform related duties as assigned

🎯 Requirements

• Master’s Degree from a recognized college or university in Human Services, Social Services, Nursing, Public Health, Public Administration, Healthcare Administration, Health Management, or a related field; a Bachelor’s Degree will be accepted for Nursing • Four (4) years of professional experience in behavioral healthcare or mental health setting • At least two (2) years performing clinical case management in a behavioral healthcare or mental health setting • 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 • 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 relevant Federal policies, rules, regulations and procedures • Knowledge of MHWIN • Knowledge of utilization management and managed care practices and principles • Knowledge of ICD-10, CPT, DSM-V or most current diagnostic edition • Knowledge of clinical care processes, including screening, assessment, treatment planning, case management, and continuing care • Knowledge of adult continuum of care for I/DD, SMI, and co-occurring disorder disability designations • Knowledge of compliance standards and Medical Necessity Criteria for Behavioral Health Services • Assessment, organizational, planning, problem-solving, decision-making, interpersonal, communication, implementation, and written communication skills • Computer skills in Word, Excel, Access, PowerPoint, Outlook, and Teams • Ability to communicate orally and in writing • Ability to work effectively with others and with an ethnically, linguistically, culturally, economically, and socially diverse population • Judgment/reasoning ability • Proof of being fully vaccinated for COVID-19 as a condition of employment, subject to legally required accommodations or exemptions

🏖️ Benefits

• Remote work possible with supervisory approval; currently primarily remote • Medical or religious accommodations and other legally required COVID-19 vaccination exemptions • Equal Opportunity Employer