Case Manager – UM II

November 25

🏄 California – Remote

Although this job is listed in California, this company may be open to hiring remote in other states.

🗽 New York – Remote

Although this job is listed in New York, this company may be open to hiring remote in other states.

+3 more states

🏄 California – Remote 🗽 New York – Remote 🌾 North Dakota – Remote ⚔️ Virginia – Remote ⛰️ West Virginia – Remote

💵 $81.2k - $116.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

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Healthfirst

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Healthcare Insurance • Finance • Medicare

Healthfirst is a health insurance provider dedicated to helping New Yorkers access affordable health coverage for individuals and families. With over 30 years of experience, Healthfirst offers a range of plans including Medicaid managed care, Medicare Advantage, long-term care, and essential health plans. The company focuses on providing quality healthcare options, comprehensive benefits, and support to ensure members can maintain their health and well-being.

1001 - 5000 employees

Founded 1993

⚕️ Healthcare Insurance

💸 Finance

📋 Description

• Provides case management services for assigned member caseloads • Pre-certification – performing risk-identification, preadmission, concurrent, and retrospective reviews • Assessment - identifying medical, psychological, and social issues • Coordination - partnering with PCP and other medical providers • Negotiates rates with non-partner providers, where applicable • Ensures appropriate access and utilization of network and community resources • Documenting - documenting all determinations, notifications, interventions, and telephone encounters • Reports and escalates questionable healthcare services • Meets performance metric requirements • Monitors assigned case load to meet performance metric requirements • Functions as a clinical resource for the multi-disciplinary care team • Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments • Occasional overtime as necessary • Additional duties as assigned

🎯 Requirements

• RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, and/or ST license • Master’s degree in a related discipline (preferred) • Experience in managed care, case management, identifying alternative care options, and discharge planning (preferred) • Certified Case Manager (preferred) • Interqual and/or Milliman knowledge (preferred) • Knowledge of Centers for Medicare & Medicaid Services (CMS) or New York State Department of Health (NYSDOH) regulations governing medical management in managed care (preferred) • Relevant clinical work experience (preferred) • Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills • Demonstrated critical thinking and assessment skills • Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

🏖️ Benefits

• medical, dental and vision coverage • incentive and recognition programs • life insurance • 401k contributions