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.