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Utilization Management Manager

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MetroPlus Health PlanNew York, NY
  • 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.
  • MetroPlus Health Plan 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, MetroPlus’ 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.
  • The Care Manager under the direction of the Sr. Director 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 Care Manager will assist the provider in directing care to the most appropriate setting, evaluating alternative care plans, and assessing outcomes through outreach to the members.
  • Performs care management including hospital admission certification, continued stay review, discharge planning, out-patient and ancillary services review, etc., following established MetroPlus 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 member‘s PCP and other providers; approves care that meets established criteria; and refers all other cases to the MetroPlus Physician Advisor/Medical Director.
  • Informs 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 assign
  • Bachelor’s Degree (BSN).
  • Licensed Practical Nurse (LPN) with hands on UM experience
  • Other Professional Licensure covering assignment scope (i.e., Physical Therapist)
  • A minimum of three to five years clinical experience in an acute care setting.
  • Excellent communication, written and analytical skills.
  • Knowledge of computer systems.
  • UM/UR experience in managed care or hospital setting required.
  • Registered Nurse, Current New York State license
  • License Practical Nurse, Current New York State license
  • Physical Therapist, New York State license

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