Utilization Management (UM) Clinical Team Lead - New York, NY

MetroPlusHealth; New York (NY); On-site; USD 80,000 - 100,000; Full time

Job summary

MetroPlus Health in New York is seeking a Clinical Team Lead to manage both simple and complex medical cases to ensure high-quality patient care outcomes. The role involves the coordination of services and evaluating care alternatives under the guidance of the Vice President of Clinical Services.

Candidates should possess a High School Diploma or GED and 2-5 years of clinical experience, with a valid New York State license for Registered Nurse or related fields. This position offers a hybrid work model.

Qualifications

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

Responsibilities

• Manage both simple and complex medical cases effectively.
• Coordinate services to improve patient care outcomes.
• Review and approve care following established guidelines.
• Conduct medical record reviews as needed.

Skills

Care management

Clinical experience

Communication skills

Analytical skills

Education

High School Diploma or GED

Job description

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

MetroPlusHealthprovides 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, MetroPlusHealthnetwork includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealthhas 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.
• Informmember 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.

#LI-Hybrid #MPH50