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Utilization Management Clinical Analyst Jobs (NOW HIRING)

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Clinical Analyst - York

York, PA · On-site

The Clinical Analyst performs medical record audit/validation processes to ensure that ... This position will provide real time feedback to management, clinical and non-clinical staff, and ...

Senior LIFE

Clinical Nursing Analyst - York

York, PA · On-site

The Clinical Analyst performs medical record audit/validation processes to ensure that ... This position will provide real time feedback to management, clinical and non-clinical staff, and ...

Senior LIFE

Clinical Nursing Analyst - York

York, PA · On-site

The Clinical Analyst performs medical record audit/validation processes to ensure that ... This position will provide real time feedback to management, clinical and non-clinical staff, and ...

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Utilization Management Clinical Analyst information

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How much do utilization management clinical analyst jobs pay per hour?

As of Jul 24, 2026, the average hourly pay for utilization management clinical analyst in the United States is $39.80, according to ZipRecruiter salary data. Most workers in this role earn between $31.49 and $45.67 per hour, depending on experience, location, and employer.

How does a Utilization Management Clinical Analyst typically collaborate with clinical and administrative teams to ensure optimal patient care?

A Utilization Management Clinical Analyst works closely with both clinical staff, such as nurses and physicians, and administrative teams to review patient cases and ensure that treatments and services are medically necessary and align with payer guidelines. This role often involves participating in interdisciplinary meetings, communicating findings and recommendations, and helping to develop or refine care protocols. Effective collaboration is essential to balance quality patient care with cost efficiency, and analysts regularly provide feedback and support to improve clinical workflows and documentation.

What are the key skills and qualifications needed to thrive as a Utilization Management Clinical Analyst, and why are they important?

To thrive as a Utilization Management Clinical Analyst, you need a solid background in healthcare, strong analytical abilities, and credentials such as RN or LPN licensure or relevant clinical certifications. Familiarity with utilization management software, electronic health records (EHRs), and claims processing systems is typically required. Excellent communication, critical thinking, and attention to detail are soft skills that help you collaborate effectively and make sound clinical determinations. These competencies are crucial for ensuring the appropriate use of medical resources, maximizing patient outcomes, and maintaining regulatory compliance.

What does a Utilization Management Clinical Analyst do?

A Utilization Management Clinical Analyst reviews and analyzes medical records, claims, and treatment plans to ensure that healthcare services provided to patients are medically necessary and cost-effective. They work with healthcare providers, insurance companies, and patients to evaluate the appropriateness of medical care based on established guidelines and policies. Their goal is to optimize patient outcomes while controlling healthcare costs and ensuring compliance with regulatory standards.

What is the difference between Utilization Management Clinical Analyst vs Utilization Review Nurse?

AspectUtilization Management Clinical AnalystUtilization Review Nurse
CredentialsHealthcare degree, certifications like CCM or CUCRegistered Nurse (RN), state licensure, certifications like CCM
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, insurance companies, outpatient facilities
Employer & IndustryHealth insurance providers, managed care organizationsHospitals, insurance companies, healthcare facilities
Common Search & ComparisonUtilization Management Clinical Analyst vs Utilization Review Nurse

The main difference between a Utilization Management Clinical Analyst and a Utilization Review Nurse lies in their focus and credentials. Clinical Analysts often have healthcare degrees and certifications like CCM, working primarily in insurance or managed care settings. Utilization Review Nurses are registered nurses with licensure, working in hospitals or outpatient facilities. Both roles involve reviewing medical necessity, but their work environments and professional backgrounds differ.

More about Utilization Management Clinical Analyst jobs
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Utilization Management Clinical Analyst jobs near you
Infographic showing various Utilization Management Clinical Analyst job openings in the United States as of July 2026, with employment types broken down into 1% Locum Tenens, 65% Full Time, 4% Part Time, and 30% Contract. Highlights an 61% Physical, 5% Hybrid, and 34% Remote job distribution, with an average salary of $82,791 per year, or $39.8 per hour.
Utilization Management Clinical Analyst - SUD HYBRID (PCN 1543)

Utilization Management Clinical Analyst - SUD HYBRID (PCN 1543)

Oakland Community Health Network

Troy, MI • On-site

$56K - $70K/yr

Full-time

Posted 22 days ago

Job description

Job Summary

The Utilization Management Clinical Analyst – Substance Use Disorder (SUD) conducts prospective and concurrent reviews of substance use disorder authorization requests to determine medical necessity and clinical appropriateness of behavioral health services in accordance with American Society of Addiction Medicine (ASAM) Level Need, Medicaid guidelines, MDHHS requirements, and the Michigan Mental Health Code. This position applies clinical expertise and evidence-based criteria to support timely utilization management decisions, promote appropriate resource utilization, and ensures quality, individualized treatment through collaboration with providers and internal stakeholders. The scope of this position includes the review of clinical care and treatment plans for the SUD provider network.


Essential Functions

    • Apply advanced clinical expertise, best practices, medical necessity criteria, Medicaid and PIHP requirements, regulatory standards, and organizational policies to determine the clinical appropriateness of SUD authorization requests.
    • Independently perform comprehensive medical necessity reviews of prospective and concurrent service authorization requests by analyzing complex clinical information, assessments, treatment plans, and supporting documentation to determine the appropriate amount, scope, duration, intensity, and ASAM level of care needed to meet assessed needs, ensuring decisions are clinically sound, timely, well-documented, and consistent with individualized treatment planning principles and applicable benefit requirements.
    • Ensure authorization decisions comply with applicable federal and state regulations, Medicaid Provider Manual requirements, ASAM guidelines, PIHP contractual obligations, evidence-based clinical guidelines, and organizational policies and procedures.
    • Analyzes records to determine legitimacy of admission, treatment, and length of stay in residential settings to comply with government and insurance company reimbursement policies analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning treatment and length of stay.
    • Review requests for transitions between ASAM levels of care and facilitate referral to the next SUD provider.
    • Determines continued stay review dates according to established clinical protocols and diagnostic criteria.
    • Complete retrospective utilization reviews to evaluate whether services provided were medically necessary, clinically appropriate, adequately documented, and delivered in the appropriate amount, scope, duration, and intensity to achieve the goals identified in the treatment plan.
    • Participate in the development, validation, implementation, and continuous improvement of utilization management policies, clinical protocols, decision-support tools, audit processes, and workflow enhancements.
    • Collaborate with internal clinical teams, provider organizations, and community partners to facilitate effective care coordination, timely communication, discharge planning, and continuity of care.
    • Participate in interdisciplinary committees, quality improvement initiatives, utilization management workgroups, and external stakeholders to support system-wide clinical quality and compliance.
    • Monitor and analyze utilization patterns, service trends, and authorization data to identify opportunities for quality improvement, ensure appropriate utilization, support regulatory compliance, and inform utilization management practices.
    • Maintain current knowledge of behavioral health standards of care and state and federal policy and regulations.
    • Perform other duties and special projects as assigned.



Job Requirements and Qualifications

Education:

  • Master’s degree in the mental health field or a relevant discipline required.

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)
    • CADC, CAADC, or development plan for the CADC/CAADC credentials.

Experience Requirements:

  • Minimum of five (5) years relevant experience providing services to Adults with Substance Use Disorder.
  • Preference for knowledge of the PIHP responsibilities for utilization management related to substance use disorder services.

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.

Knowledge Requirements

  • Michigan Mental Health Code.
  • Medicaid guidelines, regulations, and Michigan Medicaid Provider Manual.
  • Manage Care Principles and Utilization Management.
  • Demonstrated understanding of the application and outcome measurement of Substance Use Disorder Practices.
  • Knowledge of American Society of Addictions Medications (ASAM) Criteria.
  • Knowledge of substance use disorders and DSM-5.
  • Working knowledge of HIPPA and 42-CFR rules and compliance.

Job Specific Competencies/Skills:

  • Ability to work effectively in a team environment.

  • High level of understanding of various treatment processes.

  • Effective communication skills (written, oral and computer)

  • Ability to apply knowledge and evidence-based practices to complex decision-making situations.


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)

Other Information

(Travel required, physical requirements, and so on):

  • 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.