Utilization Manager

Agency Name: Detroit Wayne Integrated Health Network

Agency Contact: Jackie Hall

• Position Type: Full Time
• Job Type: Permanent
• County: Other
• Salary Range: 76,300.00 To 90,000.00 per Year
• Send applications to: https://workforcenow.adp.com/mascsr/default/mdf/recruitment/recruitment.html?cid=17aa709f-d22c-4d28-8c32-567d73bb7c5a&ccId=19000101_000001&type=MP&lang=en_US&selectedMenuKey=CareerCenter
• Please include your resume when applying.
• Download this job posting.

UTILIZATION MANAGER

Under the general supervision of the Director of Utilization Management for the Detroit Wayne Integrated Health Network (DWIHN), the Utilization Manager’s primary responsibility will be to provide clinical review and case record evaluations of all members receiving Habilitation Supports Waiver (HSW) services through the DWIHN provider network. This position will also be responsible for assessing medical necessity for auxiliary equipment and modifications.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Provides clinical review and case record evaluations for all clients receiving Habilitation Supports (HSW) services through the DWIHN provider network.
• Reviews initial applications for HSW services to determine eligibility.
• Reviews and monitors completion of recertification for HSW services.
• Monitors use of assigned HSW slots to maintain 95% or above utilization.
• Facilitates quarterly meetings with the Provider Network and reviews quarterly samples of records submitted utilizing the self-monitoring tool.
• Tracks applications for timely submission and resubmission.
• Conducts case record reviews to determine eligibility for HSW services.
• Monitors compliance with HSW services and reporting.
• Reviews individualized plans of service/person-centered plan (IPOS/PCP), progress notes, and HSW certifications, etc.
• Reviews HSW applications and certifications prior to submission to the Michigan Department of Health and Human Services (MDHHS).
• Ensures that the documentation is comprehensive and sufficient to meet the needs of all HSW enrollees.
• Accesses the MDHHS HSW database for review of HSW encounters, utilization of services and current HSW certifications.
• Provides case coordination with other Network departments including but not limited to Finance and Information Technology (IT).
• Provides on-going technical assistance to providers to ensure staff possess appropriate expertise to deliver HSW services.
• Processes applications for Private Duty Nursing to ensure timely review by the Medical Director.
• Reviews Environmental Modifications (E-MOD), Durable Medical Equipment (DME) and Enhanced Pharmacy for approvals based on medical necessity.
• Conveys the final disposition to the Provider Network in accordance with established timelines.
• Provides oversight and coordination for the Supports Intensity Scale (SIS).
• Serves as the DWIHN state liaison for SIS updates.
• Works with the two provider agencies for SIS administration as needed.
• Reviews and analyzes encounter data for the HSW Program.
• Develops monthly, quarterly and annual summary reports for the HSW Program.
• Provides education and training to provider staff, hospitals/centers, stakeholders, the Provider Network and persons served.
• Enters data and reports into Waiver Support Application (WSA) and reviews/approves access requests to WSA.
• Works with the Quality Department to monitor provider services for adherence to Federal, State and Medicaid HSW requirements.
• Works collaboratively with the Provider Network to enhance implementation of the Person-Centered Planning process for HSW recipients.
• Participates in program enhancements and the QI program. This may include data gathering, documentation and analysis.
• Develops policies and procedures which provide guidelines and standards for HSW, DME, E-MOD and Enhanced Pharmacy.
• Performs related duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES (KSA’S)

• Knowledge of the principles and practices of Utilization Management.
• 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 Habilitation Supports Waiver (HSW) guidelines.
• Knowledge of County of Financial Responsibility (COFR) guidelines.
• Knowledge of Service Utilization Guidelines.
• Knowledge of State-Wide Level of Care Guidelines and medical necessity criteria.
• Knowledge of the Medicaid Provider Manual.
• Knowledge of Federal Guidelines for Persons with Developmental Disabilities.
• Knowledge of ICD 9/10, CPT, DSMIV-TR or DSM V or most current diagnostic edition.
• Knowledge of Intermediate Care Facility/Mental Retardation (ICF/MR) criteria.
• Knowledge of Environmental Modifications (E-MOD), Durable Medical Equipment (DME) and Enhanced Pharmacy.
• Knowledge of the Supports Intensity Scale.
• Knowledge of case management principles and strategies.
• Assessment skills.
• Evaluation skills.
• Organizational skills.
• Planning skills.
• Report writing skills.
• Decision Making skills.
• Interpersonal skills.
• Communication skills.
• Collaboration skills.
• Active Listening skills.
• Computer skills (Word, Excel, Access, Power Point, Outlook, Teams).
• Teamwork 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 (a Bachelor’s Degree will be accepted), the Human Services, the Social Services or a related field.

REQUIRED EXPERIENCE:

Four (4) years of professional experience in a behavioral healthcare or mental health setting including at least two (2) years of experience performing utilization management duties and responsibilities.

REQUIRED LICENSE(S).

A Valid State of Michigan clinical licensure: RN, LMSW, LMHC, LMFT, 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.

This description is not intended to be a complete statement of job content, rather to act as 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 accommodations 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

Go to our website at https://www.dwihn.org/
Find the Careers link near the bottom of the page.
Click on the Career link.
Select the posting Utilization Manager.
Apply