Team Lead, Care Manager UM - Multiple Openings/REMOTE

Summary of Position

• Responsible for direct supervision for 5-8+ clinical staff under the guidance of a Supervisor or Lead staff member.
  
• Responsible for day to day oversight of workload balancing amongst the team members, staff assignment planning, report oversight
  
• Provide mentoring and coaching to Care Management clinical team to ensure compliance with State, Federal and NCQA requirements related to utilization and care management activities; and ensure members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time within the established guidelines and benefit sets; Preservice, Concurrent Review, Retrospective, Post-Acute and Care Management.
  
• Conduct medical appropriateness evaluations of acute care hospital admissions, post-acute care requests, and selected outpatient procedures to ensure coordination of health care delivery.
  
• Facilitate the achievement of quality clinical outcomes by integrated and collaborative interventions with multiple disciplines, Preservice, Concurrent & Post Service.
  
• Provide services per the NYCE contract.

Principal Accountabilities

• Direct oversight of team members, including 1:1 meetings and yearly performance evaluations.
  
• Provide oversight/mentoring of new employees as well as ongoing coaching for performance.
  
• Obtain guidance from senior leaders related to employee concerns, participate with Manager/Lead in PIP discussions.
  
• Act as subject matter expert in processes and procedures, use of system, delegated relationships.
  
• Identify issues with process or casework, escalate and communicate with leadership to initiate problem solving steps.
  
• Utilize Milliman (MCG) guidelines, CMS Guidelines, medical and administrative policies to evaluate medical necessity.
  
• Prepare/present clinical detail to the Medical Director for final case determination.
  
• Assist clinical care manager team to ensure cases are compliance with Emblem Health, State, Federal and NCQA requirements related to utilization and care management activities.
  
• Refer to Quality team with any questionable quality issues. Resolve escalated issues.
  
• Ensure utilization time frames are met according to regulatory guidelines (i.e., initial determination decisions, adverse determination notification to providers and members).
  
• Provide case review and ensure timely notification/correspondence to facilities, members and providers.
  
• Represent Supervisor and/or Team in projects meetings, requirements sessions, testing, etc.
  
• Participate in department educational needs, UAT testing efforts, optimization/standardization efforts, documentation.
  
• Perform other duties as assigned or required; may designate weekend coverage with and for Supervisors.