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Utilization Management Team Leader

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MetroPlus Health PlanNew York, NY
$100,000 - $118,896 Full-time
  • Job Description: Marketing Statement 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 Position Overview The Team Leader, under the direction of the Senior Director of Clinical Services providers oversight of the administration of departmental utilization management case/disease management activities.
  • 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 Senior Director of Clinical Services or Chief Medical Officer Minimum Qualifications
  • At least 2 years of managed care experience
  • Knowledge of Interqual required.
  • Prior supervisory experience preferred.
  • Computer literacy and excellent written and oral communication skills required.
  • Licensure and/or Certification Required
  • Registered Nurse with a current New York State License or Licensed Practical Nurse with significant managed care experience.
  • Integrity and Trust
  • Ability to work in a fast-paced environment.
  • High degree of diplomacy and tact.

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