BH UM Clinician

MetroPlus; New York (NY); Remote; USD 65,000 - 95,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated Behavioral Health Utilization Management Clinician to join their team. In this vital role, you will conduct utilization and quality management activities, ensuring high-quality service while managing healthcare costs. The position involves telephonic reviews, collaboration with providers, and participation in interdisciplinary meetings. If you have a passion for improving community health and possess a Master’s degree along with relevant behavioral health experience, this opportunity offers a chance to make a significant impact in the lives of New Yorkers. Join a team that values integrity, teamwork, and problem-solving in a supportive environment.

Qualifications

• 3+ years of experience in behavioral health and managed care.
• Licensure as LCSW, LMSW, or LMHC required.

Responsibilities

• Conduct telephonic reviews for inpatient and outpatient services.
• Manage medical costs through timely review activities.
• Collaborate with providers and educate on care options.

Skills

Behavioral Health Experience

Managed Care

Communication Skills

Problem-Solving

Technical Proficiency in Microsoft Office

Education

Master’s Degree

Tools

CareConnect

InterQual

LOCADTR

Microsoft Teams

Job description

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that healthcare is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlusHealth provides high-quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens, and Staten Island through various programs including Medicaid Managed Care, Medicare, Child Health Plus, and others. As a subsidiary of NYC Health + Hospitals, the largest public health system in the U.S., our network includes over 27,000 providers and clinics. For over 30 years, we have been dedicated to helping New Yorkers live healthier lives.

Position Overview

The Behavioral Health Utilization Management (BH UM) Clinician conducts utilization and quality management activities according to NY State and MetroPlusHealth policies. Responsibilities include managing medical costs through timely review activities.

Job Description

• Perform telephonic reviews for inpatient and outpatient services using InterQual, LOCADTR, and OMH Criteria Sets.
• Contribute to UM goals by containing healthcare costs and maintaining high-quality service.
• Collect and document clinical information within CareConnect.
• Promote alternative care options, research available options, and collaborate with members.
• Communicate with providers to gather clinical information and determine medical necessity.
• Discuss inpatient and outpatient requests with Medical Director, addressing non-necessity or out-of-network issues.
• Educate providers on alternative care options and medication compliance, including Long Acting Injectables.
• Participate in interdisciplinary team meetings and coordinate discharge planning.
• Identify high-risk cases for case management referral and communicate quality concerns.
• Support quality improvement, community health education, and other projects.

#LI-Remote

Minimum Qualifications

• Master’s Degree required.
• At least 3 years of behavioral health experience in managed care, including mental illness and substance use disorder.
• Experience with the Integrated Collaborative Care Model, chronic condition management, and relevant tools (e.g., LOCADTR, InterQual).
• Medical background and bilingual skills preferred.
• Licensure as LCSW, LMSW, or LMHC with a valid NY State license.

Professional Competencies:

• Integrity and Trust
• Teamwork and Problem-Solving
• Customer Service
• Technical proficiency in Microsoft Office, CareConnect, Teams
• Organizational and communication skills
• Interpersonal and assessment skills, ability to handle challenging providers