2-5 years clinical experience in an acute or applicable care setting.
Utilization Management/Utilization Review experience required in managed care or hospital setting.
Current New York State RN, LPN, or PT license required.
Strong communication and analytical skills.
Responsibilities
Manage comprehensive care delivery for all members needing care management.
Gather clinical information from PCPs and providers to support care approval.
Communicate Utilization Management determinations with members and providers.
Analyze utilization trends and member needs through data reporting.
Evaluate member referrals for appropriate case management actions.
Assist in resolving utilization management issues across departments.
Conduct medical record reviews related to cases.
Benefits
Hybrid work model flexibility.
Professional development opportunities.
Engagement in Medical Management grand rounds.
Supportive and collaborative team environment.
Full Job Description
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.
