Director of Utilization Management
Under the general supervision of the Vice President of Clinical Operations for the Detroit Wayne Integrated Health Network (DWIHN), the Director of Utilization Management is responsible for managing the day-to-day operations of the Utilization Management Program and staff. This position oversees all phases of development, organization, planning and implementation of Utilization Management projects, initiatives, work flows and processes to enhance quality-driven outcomes. The Director is expected to monitor activities that include overutilization, underutilization, standardization, implementation of new technology and assurances that DWIHN values are met.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Develops and oversees processes and procedures to ensure department-wide compliance with contractual, regulatory (Federal/State) and accreditation entities.
- Serves on the executive management team and coordinates activities with other department directors to ensure utilization management tasks are integrated with other Department functions.
- Assists the Chief Medical Officer (CMO) in facilitating the Utilization Management Committee and participates on other DWIHN committees such as Quality Assurance.
- Works closely with the Chief Medical Officer to ensure timely and accurate reviews that result in medically necessary, appropriate, efficient, and cost-effective services.
- Monitors and tracks key performance indicators to independently identify over/under utilization patterns and/or deviation from expected results.
- In collaboration with the CMO and Vice President of Clinical Operations, assists in identifying and then implementing strategies to correct trends of either over or under utilization.
- Oversees Departmental activities including, and not limited to, hospital authorizations and continued stay reviews, Self Determination activities, provider service authorization review and approval, and denial and appeals.
- Facilitates the DWIHN County of Financial Responsibility (COFR) Committee.
- Prepares statistical and narrative utilization management reports for submission to the VP of Clinical Operations on utilization patterns, expenditures by area and revenue stream, demographics of service delivery and trending of expenditures by program.
- Establishes and amends, as necessary, a reporting system for the Manager of Comprehensive Networks, Direct Service Providers, Substance Use Disorder Providers, and other stakeholders.
- Oversees UM portion of all readiness reviews (i.e External Quality Review Organization (EQRO) and Michigan Department of Health and Human Services); NCQA.
- Develops and monitors the budget for the Department while ensuring sufficient resources are assigned to meet the utilization management goals.
- Serves as the liaison for DWIHN concerning utilization management activities, including participation in external meetings and coordination with external entities.
- Works with staff to develop clear and concise development plans to ensure the advancement of the utilization management goals.
- Develops formal department-specific new staff orientation and training programs.
- Performs related duties as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES (KSA’s):
- Knowledge of DWIHN policies, procedures and practices.
- Knowledge of Utilization Management
- Knowledge of Quality Assurance.
- Knowledge of Federal policies, rules, regulations and procedures as it relates to behavioral health.
- Knowledge of Medical Necessity Criteria for Behavioral Health services, American Society of Addiction Medicine Patient Placement Criteria (ASAM) and the Federal Confidentiality Regulations, 42 CFR, Part 2.
- Knowledge of the Michigan Mental Health Code.
- Knowledge of the DWIHN provider network.
- Knowledge of medical and behavioral health practices and terminology.
- Knowledge of compliance standards.
- Knowledge of MDHHS policies, rules, regulations and procedures.
- Knowledge of budget and financial management.
- Knowledge of statistical analysis
- Knowledge of COFR policies and standards.
- Knowledge of provider appeals and the dispute resolution process.
- Knowledge of SUD treatment modalities/programs
- Supervisory skills
- Leadership skills
- Computer skills
- Time management skills
- Organizational skills
- Critical thinking skills
- Teamwork skills.
- Conflict Resolution skills.
- Decision Making skills.
- Project Management skills.
- Analytical 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 in Social Work, Psychology, Counseling, Nursing, the Human Services, the Social Services, or a related field.
REQUIRED EXPERIENCE:
Ten (10) years of experience in the mental health field.
AND
At least five (5) years of managed care experience applying UM and utilization review principles.
REQUIRED LICENSE(S).
A Valid State of Michigan clinical licensure: RN, LMSW, LMHC, LPC, LLP or PhD.
A 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. Currently this position is primarily a remote position.
This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed. Management retains the discretion to add or change the position at any time.
Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodation or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process.
The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer
