Job Summary/Objective:
The Local Care Management Lead is responsible for managing the Local Care Management (LCM) Team and overseeing utilization management activities that support the delivery of medically necessary, person-centered behavioral health services. The LCM Team is dedicated to ensuring consistent application of medical necessity criteria, authorization standards, and local standards of care while promoting high-quality outcomes for individuals receiving services.
This position works collaboratively with clinical, operational, quality, and provider network teams to ensure utilization management processes are consistent with Michigan Medicaid requirements, CCBHC standards, Community Mental Health (CMH) expectations, and organizational policies. The Local Care Management Lead will work with the Director of Clinical Quality to support organizational values, strategic initiatives, regulatory compliance, and continuous quality improvement.
Essential Duties and Functions:
- Supervises and supports the daily operations of the Local Care Management Team, ensuring timely and consistent utilization management activities.
- Oversees concurrent, retrospective, and prospective utilization reviews to ensure services meet established medical necessity criteria and local standards of care.
- Monitors authorization practices, service utilization, and level of care determinations to ensure consistency, regulatory compliance, and equitable decision making.
- Provides consultation, coaching, and education to clinical staff regarding medical necessity criteria, utilization management processes, documentation expectations, and local standards of care.
- Reviews utilization trends, authorization data, and quality metrics to identify opportunities for improvement and reduce variation in clinical decision-making.
- Leads audits of utilization management processes and documentation, develops corrective action plans, and monitors implementation of identified improvements.
- Collaborates with Clinical Quality, Quality Assurance, Provider Network, Finance, and Program Leadership to support coordinated quality improvement initiatives.
- Maintains and updates local utilization management procedures, standards of care, and related policies to ensure alignment with MDHHS, CCBHC, and managed care requirements.
- Prepares and presents utilization management reports, performance measures, and quality indicators to organizational leadership.
- Acts as a member of the Summit Pointe Management System team by managing assigned key performance indicators, supporting annual strategy development, and leading continuous improvement initiatives for the Local Care Management department.
- Maintains confidentiality and privacy in accordance with HIPAA, 42 CFR Part 2, MDHHS, and all applicable state and federal regulations.
- Performs other duties as required.
Qualifications:
- Master's degree in Social Work, Psychology, Counseling, or another behavioral health-related field.
- Current Michigan clinical licensure.
- Minimum of three years of behavioral health clinical experience, including experience with utilization management, care management, or clinical quality activities.
- Previous supervisory, team lead, or project leadership experience preferred.
- Demonstrated knowledge of medical necessity criteria, utilization management principles, behavioral health standards of care, and person-centered planning.
- Knowledge of Michigan Medicaid, Community Mental Health (CMH), CCBHC, and regulatory requirements.
- Experience analyzing utilization, quality, or performance data to support continuous improvement initiatives.
- Strong organizational, communication, problem-solving, and leadership skills with proficiency in electronic medical record systems and Microsoft Office applications.
- Experience with quality improvement methodologies, audit processes, or regulatory review activities preferred.
Trauma Informed System of Care:
A trauma-informed approach to service delivery emphasizes physical and emotional safety, choice, empowerment, and trustworthiness for customers. The impact of trauma is broad and touches many life domains. Participation is mandatory for activities required for Summit Pointe to become a “Trauma Informed System of Care.”
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