Utilization Review Supervisor (PCN 1547)

Job Summary

The Supervisor of Utilization Review (UR) oversees the development, implementation, and maintenance of Utilization Review (UR) clinical policies, procedures, and protocols. This position supervises UR Analysts and Acute Care Authorization Analysts and provides clinical and operational oversight for crisis authorizations, concurrent reviews, acute care utilization, high-risk cases, care coordination, and discharge planning. The UR Supervisor collaborates with providers, hospitals, state facilities, community partners, and internal OCHN departments to ensure appropriate, effective, and efficient use of resources.

Responsibilities

• Support NCQA compliance, MDHHS reporting, appeals and due process requirements, case consultation, quality improvement initiatives, and data analysis.
• Participate in management meetings, workgroups, and strategic initiatives while ensuring compliance with regulatory, accreditation, and organizational standards.
• Supervise and evaluate UR and Acute Care Authorization staff to ensure adherence to clinical criteria, business rules, regulatory requirements, and organizational policies.
• Provide leadership, oversight, and support for Acute Care Authorization staff responsible for 24/7 operations, ensuring continuity of services, timely decision-making, and compliance with organizational and regulatory requirements.
• Oversee reviews of admissions, continued stays, and lengths of stay to ensure clinical appropriateness and compliance with reimbursement, accreditation, and regulatory standards.
• Provide clinical oversight, advocacy, and authorization support for individuals requiring acute care, State Facility placement, enhanced staffing, or higher levels of care.
• Collaborate with network providers, acute care hospitals, state psychiatric facilities, and interdisciplinary treatment teams to facilitate utilization review activities, continuity of care, and effective discharge planning.
• Ensure timely and comprehensive review of clinical information, including accurate documentation of decisions and supporting rationale.
• Lead onboarding, training, coaching, and inter-rater reliability activities, including use of the MCG Parity Tool.
• Develop, implement, and maintain utilization of review policies, procedures, protocols, and quality improvement initiatives, including those related to NCQA and HSAG requirements.
• Monitor compliance with authorization, denial, appeal, and reporting requirements established by MDHHS, NCQA, and other regulatory agencies.
• Analyze, monitor, and report utilization data, including hospital census, admissions, discharges, lengths of stay, recidivism, and staff performance trends to identify improvement opportunities.
• Participate in organizational committees, workgroups, and initiatives.
• Represent the Utilization Review department in meetings and special projects assigned by leadership.
• Participate in quality improvement initiatives, interdisciplinary workgroups, provider collaboration, audits, appeals, and other utilization management and review activities to support organizational performance and regulatory compliance.
• Perform other duties as assigned.

Job Requirements and Qualifications

• Education: Master's degree in mental health field.
• Training Requirements: 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).
• Experience Requirements: Minimum of five (5) years relevant experience providing services to Adults with Mental Illness, Intellectual or Developmental Disabilities, Substance Use Disorder and/or children with serious emotional disturbance or intellectual or Development Disabilities. Preferred Experience: Experience within a Community Mental Health Services Program (CMHSP), Prepaid Inpatient Health Plan (PIHP), Managed Care Organization (MCO), hospital, or behavioral health setting. Experience with NCQA, MDHHS, HSAG, and/or accreditation and regulatory compliance activities. Experience with utilization of the MCG Parity Tool. Experience within the Oakland Community Health Network (OCHN) provider network.
• Knowledge Requirements: Knowledge of the Michigan Mental Health Code. Medicaid rules, regulations, and Michigan Medicaid Provider Manual. Preference for knowledge of the PIHP responsibilities for utilization management Managed Care and Utilization Management Principles.

Job Specific Competencies/Skills

• Demonstrated strong interpersonal skills with a proven ability to collaborate effectively in cross-functional and team-oriented environments.
• Skilled in negotiation and stakeholder engagement, fostering productive relationships, and achieving mutually beneficial outcomes.
• Excellent written and verbal communication skills, with the ability to convey complex information clearly and professionally.
• Proficient in computer applications and project management practices, ensuring efficient coordination, execution, and successful delivery of initiatives.
• In addition, the following are preferred competencies: Demonstrated experience in quality assurance and quality monitoring Demonstrated experience in the application of medical necessity Demonstrated experience in data analysis and outcome measurement Demonstrated understanding of the application and outcome measurement of Evidence Based Practice.

Oakland Community Health Network’s Core Competencies

• Interacting with others in a way that gives them confidence in one’s intentions and those of the organization; demonstrating loyalty to the organization and its mission and values; maintaining social, ethical, and organizational norms; firmly adhering to codes of conduct and ethical principles.
• Making customers and their needs a primary focus of one’s actions; developing and sustaining productive customer relationships, recognizing that the ultimate customer is the person served.
• Actively identifying new areas for learning; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill on the job and learning through their application.
• Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence in addition to consciously adopting organizational standards of excellence.
• Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.