BH UM Clinician

MetroPlus Health 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 Health 's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 40 years, MetroPlus Health has been committed to building strong relationships with its members and providers.

Position Overview:

Empower. Unite. Care.

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.

The Behavioral Health Utilization Management (BH UM) Clinician is responsible for conducting utilization and quality management activities in accordance with New York State and MetroPlusHealth Utilization Management policies and procedures. The position responsibilities include the management of medical costs through timely prospective, concurrent, and retrospective review activities.

Duties & Responsibilities

• Performs telephonic review for inpatient and outpatient services using InterQual with Secondary Dimensions & LOCADTR and OMH Criteria Sets
• Contributes to UM program goals and objectives in containing health care costs and maintains a high-quality medical delivery system through departmental UM procedures
• Collects all pertinent clinical information and documents within CareConnect
• Promotes alternative care programs and research available options including costs and appropriateness of patient placement in collaboration with health plan members
• Communicates directly with Physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
• Communicates with Medical Director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues
• Recommends, coordinates, and educates providers regarding alternative care options
• Educate providers on medication and treatment compliance while also promoting the use of Long Acting Injectables
• Enlist existing provider network in promoting first episode psychosis treatment.
• Educate providers to alternate treatment services being promoted by Health + Hospitals in lieu of Inpatient Detox
• Attends and prepares for bi-Weekly Interdisciplinary Care Team (ICT) meetings which will feature newly enrolled, frequently admitted, high utilizing at risk CORE and HARP members
• Evaluate housing needs-Collaborating timely with MetroPlusHealth internal housing team for supportive assistance
• Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planning staff
• Identifies potentially catastrophic and high-risk cases for case management referral
• Identifies and communicates all potential quality of care concerns to the BH UM Clinician Team Lead in a timely manner
• Contributes to MetroPlusHealth corporate goals through ongoing active team participation, offering input and assistance with development and delivery of education and trainings.
• Performs other appropriate UM Behavioral Health duties and participates in other special projects as assigned, including, but not limited to, monthly audit review and preparation, quality improvement, community health education, facility/provider relations and marketing activities.
• Support Coverage for Retrospective Reviews and BH UM Appeals as needed

Minimum Qualifications

Master's Degree required

Minimum 3 years of Behavioral Health (Serious Mental Illness & Substance Use Disorder) experience in managed care utilization review, quality assurance, discharge planning. (Experience working in a Psychiatric Hospital Inpatient and/or Outpatient setting preferred)

Previous Experience within the Integrated Collaborative Care Model Approach

Experience with chronic condition management, particularly Diabetes, HIV, Heart Disease


Pharmacy, Psyckes, E-Paces, LOCADTR, InterQual, Guiding Principles, HCS (UAS) MAPP,


Medical Background & Bilingual preferred

Previous Quality Management liaison experience with hospitals and other large volume providers to address cost. as well as HEDIS/QARR quality performance, preferred.

Licensure and/or Certification Required:

• LCSW, LMSW, or LMHC. Current valid unrestricted NY State License.

Professional Competencies:

• Integrity and Trust
• Teamwork and Problem-Solving Attitude
• Customer Service
• Superior Technical Computer skills (Microsoft Office, Care Connect, Teams Video Application)
• Exceptional Organizational and Communication Skills.
• Strong interpersonal and assessment skills, the ability to remain calm and poised with challenging providers