Utilization Management (UM) Clinical Team Lead (RN, LPN or PT)

MetroPlusHealth; New York (NY); On-site; USD 110,000 - 140,000; Full time

Job summary

MetroPlusHealth in New York is seeking a Clinical Team Lead to manage simple and complex medical cases, coordinate outpatient and inpatient care, and guide care plans to achieve high-quality outcomes while minimizing unnecessary costs.

You will collaborate with PCPs and specialists, review utilization, perform medical record reviews, and participate in Medical Management rounds under the VP of Clinical Services.

Qualifications

• GED required; high school equivalency recognized.
• 2-5 years of clinical experience in an acute or applicable care setting.
• UM/UR experience in managed care or hospital setting required.

Responsibilities

• Performs care management including hospital admission certification, continued stay review, discharge planning, outpatient, and ancillary services review, following established MetroPlusHealth UM policies and procedures.
• Oversee the coordination and delivery of comprehensive, quality healthcare and services for all members requiring care management in a cost-effective manner.
• Interacts with members' PCP and other providers; approves care that meets established criteria; and refers 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 generating reports of encounter data and health assessments.
• Evaluate member needs for referred cases (from providers or member self-referred).
• Assists departments with the resolution of members' problems related to utilization management issues.
• Performs all UM activities in compliance with regulatory 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

Skills

Integrity and Trust

Customer Focus

Communication Skills

Analytical Thinking

Computer Literacy

Education

GED or equivalent

New York State License (RN/LPN/PT)

Job description

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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