UM Clinical Team Lead

Marketing Statement

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, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

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.

The Utilization Management (UM) Clinical Team Lead, under the direction of the Director of Utilization Management provides oversight of the administration of departmental utilization management activities.

Job Description

• Supervise staff conduct utilization review.
• Oversee utilization review activities and ensures cases are reviewed timely meeting NYS DOH and CMS regulatory standards.
• Support care management team development through direct staff training and development activities
• Conduct utilization review and quality of care monitoring activities in conjunction with care management program staff
• Quarterly audits of clinical staff
• Investigation and resolution of clinical claims related issues
• Support departmental training and clinical quality improvement activities.
• Participate in the development, implementation, and evaluation of performance improvement initiatives
• Ensure that standards of care delivery are consistent with current professional standards and consistent with the Mission, Vision and Values of the organization.
• Actively participate in Article 44/49 and CMS audit activities
• Participate in committees, as assigned.
• Other responsibilities as directed by the Director of Utilization Management or Vice President of Clinical Services.
  
  

Minimum Qualifications

• High School Degree or General Equivalency Diploma (GED) required
• At least 4 years of Utilization Management experience required.
• Strong working knowledge of InterQual required.
• At least 1 year of supervisory experience.
• Computer literacy and excellent written and oral communication skills required
• Registered Nurse with a current New York State License, Licensed Practical Nurse, or Physician Assistant with significant managed care experience.
  
  

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Written/Oral Communications
• Ability to work in a fast-paced environment.
• High degree of diplomacy and tact
  
  

Department Preferences