Clinical Utilization Lead – Care Coordination & Outcomes

MetroPlusHealth; New York (NY); On-site; USD 90,000 - 120,000; Full time

Job summary

MetroPlusHealth is seeking a Clinical Team Lead to manage simple and complex medical cases and coordinate outpatient and inpatient services. The role requires directing care to the most appropriate setting and evaluating outcomes through member outreach.

The position reports to the Vice President of Clinical Services and includes oversight of utilization management activities while collaborating with PCPs and providers to ensure high-quality care and cost-effective services for MetroPlusHealth

Qualifications

• GED or high school diploma required.
• 2-5 years clinical experience in acute care.
• UM/UR experience in managed care or hospital setting required.

Responsibilities

• Performs care management including admission certification and discharge planning.
• Oversee coordination for cost-effective, quality healthcare for all members.
• Communicates with PCPs and providers; approves care per criteria.
• Identifies utilization trends using encounter data and pharmacy data.
• Assists departments with utilization management issue resolutions.
• Conducts medical record reviews for case management.
• Participates in Medical Management grand rounds.
• Performs other duties as assigned.

Skills

Integrity and Trust

Customer Focus

Written communication

Analytical skills

Computer skills

Education

GED

Job description

MetroPlusHealth is seeking a Clinical Team Lead to manage simple and complex medical cases and coordinate outpatient and inpatient services. The role requires directing care to the most appropriate setting and evaluating outcomes through member outreach.

The position reports to the Vice President of Clinical Services and includes oversight of utilization management activities while collaborating with PCPs and providers to ensure high-quality care and cost-effective services for MetroPlusHealth