Utilization Management (UM) Clinical Team Lead

About the role

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.

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).
• Affords assistance to 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.
• Participates in Medical Management grand rounds with the Physician Advisor.
• Performs all other duties as assigned.

Minimum Qualifications

• A High School Diploma 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.

Licenses and Certifications Required

• A 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).