BH UM Clinician

MetroPlus Health Plan; New York (NY); Remote; USD 87,000; Full time

Job summary

An established industry player is seeking a dedicated Behavioral Health Utilization Management Clinician to join their team. This fully remote role involves conducting utilization and quality management activities to ensure high-quality healthcare delivery. You will manage medical costs through thorough reviews, educate providers on care options, and participate in interdisciplinary meetings for high-risk members. The ideal candidate will possess a Master's degree and have a strong background in behavioral health utilization review. Join a mission-driven organization committed to empowering communities and making a positive impact on healthcare services.

Qualifications

• Master's Degree required with 3+ years in behavioral health utilization review.
• Knowledge of clinical tools like InterQual and LOCADTR is essential.

Responsibilities

• Conduct telephonic reviews for inpatient and outpatient services.
• Document clinical information and promote alternative care programs.

Skills

Behavioral Health Utilization Review

Quality Assurance

Discharge Planning

Integrated Care Models

Chronic Condition Management

Clinical Documentation

Interpersonal Skills

Education

Master's Degree

Tools

InterQual

LOCADTR

CareConnect

Job description

BH UM Clinician - Fully remote

Job Ref: 121609

Category: Utilization Review and Case Management

Department: BEHAVIORAL HEALTH HARP

Location: 50 Water Street, 7th Floor, New York, NY 10004

Job Type: Regular

Employment Type: Full-Time

Hire In Rate: $86,500.00

Salary Range: $86,500.00 - $86,500.00

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 building strong relationships with our members and providers to promote health and wellness.

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 prospective, concurrent, and retrospective reviews.

Job Responsibilities

1. Perform telephonic reviews for inpatient and outpatient services using InterQual, LOCADTR, and OMH Criteria Sets.
2. Contribute to UM program goals to contain healthcare costs and maintain high-quality medical delivery.
3. Document clinical information within CareConnect.
4. Promote alternative care programs and research options including costs and appropriateness of patient placement.
5. Communicate with providers to gather clinical information and determine medical necessity.
6. Discuss inpatient and outpatient requests with Medical Director, especially those not meeting medical necessity or involving out-of-network transfers.
7. Coordinate and educate providers on alternative care options.
8. Educate providers on medication and treatment compliance, including Long Acting Injectables.
9. Participate in interdisciplinary team meetings for high-risk members.
10. Evaluate housing needs and collaborate with the housing team.
11. Ensure continuity of care through discharge planning and collaboration with hospital staff.
12. Identify high-risk cases for case management referral.
13. Report quality concerns to the team lead promptly.
14. Participate in team activities, education, and special projects.
15. Support retrospective reviews and appeals as needed.

Minimum Qualifications

• Master's Degree required.
• At least 3 years of experience in behavioral health utilization review, quality assurance, or discharge planning, preferably in psychiatric settings.
• Experience with integrated care models and chronic condition management.
• Knowledge of pharmacy, LOCADTR, InterQual, and other clinical tools.
• Medical background and bilingual skills preferred.
• Previous experience with hospital quality management and HEDIS/QARR metrics is a plus.

Licensure and Professional Competencies

• NY State License: LCSW, LMSW, or LMHC.
• Core competencies include integrity, teamwork, customer service, technical skills, organizational ability, and interpersonal skills.