Clinical Operations Manager - Behavioral Health UM

MetroPlusHealth 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, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The BH UM Clinical Operations Manager reports to the Vice President of Behavioral Health and is responsible for the day-to-day work to ensure successful implementation of new system and ongoing system enhancements for all aspects of utilization management activities. The BH UM Clinical Operations Manager is the subject matter expert for all BH UM operational workflows, letter template management, authorization related claims issues, benefit configurations, reporting, and regulatory and contractual compliance. This includes working collaboratively with subject matter experts conducting BH UM/Care Management (CM)/Disease Management (DM) as well as other related areas that impact utilization processes and outcomes (claims, membership, provider network).

The BH UM Clinical Operations Manager is responsible for new system implementation and ongoing system enhancements including UM intake, UM case set up, clinical review process, regulatory and contractual out of network requests/redirection, admin denials, authorization-related claims issues, third party vendor activities, and regulatory compliance. This manager will work closely with the Director of BH Utilization Management to ensure all UM deliverables are met and all related escalations are addressed.

Job Description

• Ensure overall comprehensive knowledge of current state of BH Utilization Management operations.
• Proactively gather and elicit information to understand current state, pain points, and desired future state to identify best practices based on new system capabilities.
• Analyze workflows and processes and use experiential UM industry knowledge to recommend meaningful solutions based on new system capabilities in order to maximize efficiencies.
• Utilize data and insights learned to support decision making.
• Work with members of the system implementation team to ensure critical operational and regulatory components are accounted for.
• Actively participate in all aspects of system implementation including analysis, testing and validation activities. Escalate critical issues that may impact operational efficiencies, cost containment strategies, claims and benefit configuration and regulatory compliance.
• Review and verify BH UM related documentation of system implementation for compliance and operational accuracy. Review documentation of collateral areas and provide feedback of decisions that will have unintended critical consequence of UM operations.
• Effectively communicate with all stakeholders ensuring appropriate and timely updates.
• Help develop future state workflow processes ensuring inclusion of all regulatory and NYS DOH contractual requirements.
• Actively participate in reporting development to support real-time compliance monitoring, productivity, and utilization operational trend reports.
• Develop training documents for both clinical and non-clinical staff, to support successful transition to new system.
• Ensure post-implementation monitoring to address issues identified including but not limited to training, workflow updates, or system enhancements.
• Monitor authorization-related claim issues and identify systemic trends amendable to workflow process changes and system enhancements.
• Actively participate in the evaluation and implementation of new benefits and regulatory guidance changes.
• Actively participate in meetings with HealthEdge support team to drive system enhancements and resolution to identified system issues.
• Conduct analysis, testing and validation activities for future system enhancements and work with BH UM Team Lead and clinicians, and trainers to ensure successful implementation.
• Other responsibilities as directed by the VP of Behavioral Health and Director of BH Utilization Management.

Minimum Qualifications

• Master's degree or higher required
• 8 - 10 years of comprehensive BH Utilization Management experience with a health plan which includes benefit configuration, claims, BH CPT, and ICD-10 codes.
• 5+ years of successful operational or project management experience in a managed care with Medicaid, Medical and Commercial Lines of Businesses.
• Ability to apply innovative approaches to solve problems in a timely and efficient manner.
• Minimum of three years supervisory experience.
• Knowledge of NYS Medicaid Model Contract, NYS Parity requirements, CMS requirements, OMH and OASAS guiding principles and regulations and NYS Article 44/49 requirements

Licensure and/or Certification Required:

• LMSW, LCSW, LMHC or Licensed Psychologist required

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Written/Oral Communications

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