Utilization Management (UM) Clinical Team Lead

MetroPlusHealth; New York (NY); Sur place; USD 90 000 - 120 000; Plein temps

Résumé du poste

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.

Responsabilités

• 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.

Connaissances

Integrity and Trust

Customer Focus

Written communication

Analytical skills

Computer skills

Formation

GED

Description du poste

Empower. Unite. Care. MetroPlus

Empower. Unite. Care. MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care 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 the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers.

Position Overview

The Clinical Team Lead, under the direction of the Vice President of Clinical Services, is primarily responsible for managing both simple and complex medical cases to achieve high-quality patient care outcomes and minimize unnecessary medical expenses, through the coordination of services, both outpatient and inpatient. The Clinical Team Lead will assist the provider in directing care to the most appropriate setting, evaluating alternative care plans, and assessing outcomes through outreach to the members.

Work Shifts

9:00 AM - 5:00 PM

Duties & Responsibilities

• Performs care management including hospital admission certification, continued stay review, discharge planning, outpatient, and ancillary services review, etc., following established MetroPlusHealth Utilization Management policies, procedures, and protocols.
• Oversee the coordination and delivery of comprehensive, quality healthcare and services for all members requiring care management in a cost-effective manner.
• Interacts and obtains relevant clinical information from members' PCP and other providers; approves care that meets established criteria; and refers all other cases to the MetroPlusHealth Physician Advisor/Medical Director.
• Inform member and provider of Utilization Management determinations and treatment alternatives.
• Identifies utilization trends and potential member needs by means of generating reports of encounter data, pharmacy data review, and new member health assessment forms.
• Evaluate member needs for referred cases (from providers or member self-referred).
• Assists all departments with the resolution of members' problems related to utilization management issues.
• Performs all Utilization Management activities in compliance with all regulatory agency requirements.
• Conducts medical record reviews as appropriate to case management functions.
• Participate in Medical Management grand rounds with the Physician Advisor.
• Performs all other duties as assigned

Minimum Qualifications

• High School Diploma General Equivalency Diploma (GED) required; and
• 2-5 years' clinical experience in an acute or applicable care setting.
• UM/UR experience in managed care or hospital setting required

Licensure And/or Certification Required

• Valid New York State license and current registration to practice as a Registered Professional Nurse (RN), License Practical Nurse (LPN), or Physical Therapist (PT) issued by the New York State Education Department (NYSED).

Professional Competencies

• Integrity and Trust
• Customer Focus
• Excellent communication, written and analytical skills.
• Knowledge of computer systems.

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