Job #: 2197
Title: Utilization Management Lead
The Team Leader, Under the Direction of the Director of Utilization Operations, assists in the day-to-day activities and evaluation of utilization activities. Monitor utilization review activities and outcomes. The Team Leader is responsible for staff assigned to Utilization Management.
· Assist the Associate Director with creation of reports and managing department timesheets/requests for time off, .
· Supervise the clinical and support staff responsible for Global Utilization review and monitoring.
· Monitor Care Manager performance, identify opportunities for efficiencies, work with staff to close any deficiencies
· Ramp up new hires to meet Departmental goals for performance.
· Support Member Care Management and utilization review activities in conjunction with Case Management/Utilization review teams.
· Support Utilization Management team development through direct staff training and development activities.
· Promote and facilitate a multidisciplinary approach to coordinate care and plan operations among disciplines. Ensure adherence to standards of care consistent with current professional standards and consistent with the Mission, Vision and Values of the Organization.
· Conduct Utilization Review audits and quality of care monitoring activities including appropriateness of inpatient, skilled nursing facility and acute rehabilitation admissions, transitions of care, Behavioral Health and home health services.
· Participate in the development, implementation, and evaluation of quality improvement and performance improvement initiatives and other related projects within utilization management.
· Participate in committees as assigned.
· Investigation and resolution of clinical claims related issues.
· Oversee that all Care Manager are following UM processes.
· Review denial letters submitted by all UM nurses for content and accuracy.
· Assist with developing new work flow for UM and Policy changes on applicable regulatory guidelines.
· Be UM content expert for UM Processes.
· Assist in UM Care Managers Quarterly Audit.
· Performs all UM activities in compliance with all regulatory agency requirements.
· Assist all MetroPlus departments with the resolution of the members issues related to Utilization Management.
· Performs all other duties as required, requested or assigned.
· Bachelor’s Degree in Nursing (BSN) preferred
· Experience in Utilization Management required
· Knowledge of the principals surrounding Care Management Standard of Practice
· minimum of two years clinical experience in an acute care setting
Licensure and/or Certification Required
· Registered Nurse with current New York State Nursing license
· Or Diploma from foreign medical school
· Integrity and Trust
· Customer Focus
· Functional/Technical Skills
· Written/Oral Communications