Clinical Utilization Management Lead - Care Team

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

Job summary

MetroPlus Health in New York is seeking a Clinical Team Lead to manage complex medical cases and coordinate care across outpatient and inpatient settings. You will guide care to appropriate settings, evaluate outcomes, and support outreach to members under the direction of the VP of Clinical Services.

Ideal candidates bring 2–5 years of clinical experience in acute care, NYS RN/LPN/PT licensure, and UM/UR experience.

Qualifications

• GED or high school diploma required; 2–5 years of clinical experience in acute or applicable care.
• UM/UR experience in managed care or hospital setting required.
• Current NYS license and registration to practice (RN/LPN/PT).

Responsibilities

• Performs care management including hospital admission certification and discharge planning.
• Oversee the coordination and delivery of comprehensive, quality healthcare for members.
• Interacts with members' PCP and other providers; approves care meeting criteria.
• Inform member and provider of utilization management determinations.
• Conduct medical record reviews and participate in Medical Management rounds.

Skills

Excellent communication

Integrity and Trust

Customer Focus

Knowledge of computer systems

Education

RN/LPN/PT license (NYSED)

High School Diploma / GED

Job description

MetroPlus Health in New York is seeking a Clinical Team Lead to manage complex medical cases and coordinate care across outpatient and inpatient settings. You will guide care to appropriate settings, evaluate outcomes, and support outreach to members under the direction of the VP of Clinical Services.

Ideal candidates bring 2–5 years of clinical experience in acute care, NYS RN/LPN/PT licensure, and UM/UR experience.