Utilization Management (UM) Clinical Team Lead

MetroPlusHealth; New York (NY); On-site; USD 75,000 - 90,000; Full time

Job summary

MetroPlusHealth in New York is seeking a Clinical Team Lead responsible for managing medical cases to ensure high-quality patient care outcomes. This role involves coordinating outpatient and inpatient services while working closely with healthcare providers.

The ideal candidate should have a strong background in clinical settings, possess a New York State nursing or therapy license, and demonstrate excellent communication and analytical skills.

MetroPlusHealth values integrity, customer focus, and teamwork. Apply to join a company committed to empowering New Yorkers.

Qualifications

• 2-5 years' clinical experience in an acute or applicable care setting.
• UM/UR experience in managed care or hospital setting required.
• Valid NY State license as RN, LPN, or PT.

Responsibilities

• Manage simple and complex medical cases for quality patient outcomes.
• Oversee coordination and delivery of healthcare services.
• Perform care management including hospital admission certification.

Skills

Strong clinical skills

Excellent communication skills

Analytical skills

Knowledge of health care regulations

Education

High School Diploma or GED

Job description

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 or General Equivalency Diploma (GED) required.
• 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), Licensed 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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