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Utilization Care Manager Jobs in Michigan (NOW HIRING)

UHS

Manager of Utilization Review

Saint Johns, MI · On-site

Cedar Creek Hospital Description The Manager of Utilization Review is responsible for managing and ... Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory ...

McLaren

Social Work Care Manager

Pontiac, MI · On-site

... Care Manager referrals to social work based on identified Social Work Triggers (see SW Referral ... Uses knowledge of insurance benefits and coverage guidelines to maximize appropriate utilization of ...

UHS

Manager of Utilization Review

Saint Johns, MI · On-site

Cedar Creek Hospital Description The Manager of Utilization Review is responsible for managing and ... Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory ...

UHS

Manager of Utilization Review

Saint Johns, MI

Cedar Creek Hospital Description The Manager of Utilization Review is responsible for managing and ... Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory ...

UHS

Manager of Utilization Review

Saint Johns, MI · On-site

Cedar Creek Hospital Description The Manager of Utilization Review is responsible for managing and ... Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory ...

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Utilization Care Manager information

What is a utilization care manager?

Utilization Care Managers are healthcare professionals responsible for evaluating the necessity, appropriateness, and efficiency of medical services provided to patients. They work to ensure that patients receive the right care at the right time, while also helping healthcare organizations manage costs and comply with regulations. Utilization Care Managers often review patient cases, coordinate with medical staff, and interact with insurance companies to authorize or deny services. Their goal is to optimize healthcare delivery, reduce unnecessary procedures, and improve patient outcomes.

How does a utilization care manager collaborate with medical and administrative teams to ensure effective patient care?

Utilization Care Managers work closely with physicians, nursing staff, and administrative teams to review patient cases, determine medical necessity, and coordinate appropriate care plans. They frequently participate in interdisciplinary meetings, communicate with insurance providers regarding authorizations, and ensure compliance with regulatory guidelines. This collaborative approach helps to optimize resource utilization, improve patient outcomes, and support smooth transitions of care. Being proactive in communication and documentation is key to success in this role.

What are the key skills and qualifications needed to thrive as a utilization care manager, and why are they important?

To thrive as a Utilization Care Manager, you need a background in healthcare, typically as a registered nurse or social worker, with expertise in care coordination and utilization review. Familiarity with utilization management software, medical necessity guidelines (such as Milliman or InterQual), and knowledge of insurance regulations are important. Strong analytical thinking, attention to detail, and effective communication skills help you advocate for patients while working with healthcare teams and payers. These skills ensure appropriate resource use, quality patient outcomes, and compliance with regulatory standards.

What is the difference between Utilization Care Manager vs Utilization Review Nurse?

AspectUtilization Care ManagerUtilization Review Nurse
CredentialsRN, case management certificationRN, certification in utilization review
Work EnvironmentHealthcare facilities, insurance companiesHospitals, insurance companies, outpatient clinics
Primary FocusCoordinating patient care, managing resourcesReviewing medical necessity, approving treatments

Utilization Care Managers focus on coordinating patient care and managing resources, while Utilization Review Nurses primarily evaluate medical necessity for treatments. Both roles require nursing credentials and work within healthcare or insurance settings, but their core responsibilities differ in scope and focus.

What does a utilization care manager do in healthcare?

A utilization care manager in healthcare reviews patient cases to ensure appropriate use of medical services and resources, coordinating care plans to optimize patient outcomes and reduce unnecessary costs. They often work with healthcare providers, insurance companies, and patients, using data and clinical guidelines to make informed decisions about treatment and service utilization.

What are popular job titles related to Utilization Care Manager jobs in Michigan?

For Utilization Care Manager jobs in Michigan, the most frequently searched job titles are:

What job categories do people searching Utilization Care Manager jobs in Michigan look for?

The top searched job categories for Utilization Care Manager jobs in Michigan are:

What cities in Michigan are hiring for Utilization Care Manager jobs?

Cities in Michigan with the most Utilization Care Manager job openings:

Utilization Care Manager jobs near you

Utilization Review Supervisor (PCN 1547)

Oakland Community Health Network

Troy, MI • On-site

$70K - $87K/yr

Full-time

Re-posted 18 days ago

Job description

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 include supporting NCQA compliance, MDHHS reporting, appeals and due process requirements, case consultation, quality improvement initiatives, and data analysis. The position also participates in management meetings, workgroups, and strategic initiatives while ensuring compliance with regulatory, accreditation, and organizational standards.

Essential Functions

  • Supervise and evaluate Utilization Review (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 (licenses, programs, or certificates):

      • 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)
        ​Must maintain Child Diagnostic and Treatment Professional (CDTP) eligibility, including 24 hours of annual child-specific training.

Experience Requirements:

  • Minimum of three (3) years of relevant post-graduate clinical experience providing services to adults with mental illness, intellectual or developmental disabilities, and/or substance use disorders, as well as children with serious emotional disturbance and/or intellectual or developmental 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 withutilizationofthe 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 forutilizationmanagement.
  • Managed Care and Utilization ManagementPrinciples

Job Specific Competencies/Skills

  • Demonstratedstrong interpersonal skills with a proven ability to collaborate effectively in cross-functional and team-oriented environments.
  • Skilled in negotiation and stakeholder engagement, fostering productiverelationships,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 Practices.

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. (Integrity/Building Trust)
  • 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. (Customer Focus)
  • 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. (Continuous Learning)
  • 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. (Work Standards)
  • 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. (Communication)

Additional Information

(Travel required, physical requirements, schedules, etc.):

  • Must have available means of transportation to and from OCHN and for required offsite meetings or site visits.
  • Must be available for meetings and events which may occur outside of standard office hours.
  • Work performed primarily in an office environment.
  • Hybrid (onsite/remote) work schedule available.
  • The ideal candidate must be able to complete all physical requirements of the job with or without a reasonable accommodation.

OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees' differences. This includes (but is not limited to) ability, age, color, family type, gender expression and identity, individual expression, medical conditions, national origin, pregnancy, race, religion, sexual orientation, veteran status, and all other diverse and wonderful characteristics.