Manager, Clinical Utilization Management

🕒 il y a 4 jours

🦌 Connecticut, Florida, +3 états de plus – Distant

🦌 Connecticut – Remote 🐊 Florida – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $88 700 - $149 430 / an

⏰ Temps Plein

🟡 Intermédiaire

🟠 Senior

👔 Manager

🦅 Parrain de Visa H1B

Cette entreprise a parrainé des visas H1B par le passé.

👻 Score fantôme 0%

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Healthfirst

Site WebLinkedInTous les Emplois

1001 - 5000 employés

Fondée en 1993

🛡️ Assurance

🏥 Santé

⚕️ Assurance santé

Insurance • Healthcare • Healthcare Insurance

Healthfirst est un fournisseur d'assurance santé dédié à aider les New-Yorkais à accéder à une couverture santé abordable pour les particuliers et les familles. Avec plus de 30 ans d'expérience, Healthfirst propose une gamme de plans incluant des soins gérés par Medicaid, des Medicare Advantage, des soins de longue durée, et des plans de santé essentiels. L'entreprise se concentre sur la fourniture d'options de soins de santé de qualité, de bénéfices complets, et d'un soutien pour garantir que les membres puissent maintenir leur santé et leur bien-être.

Description

• Provide daily oversight for Case Management teams, including RNs, Social Workers, and Coordinators • Ensure high-quality, cost-effective, and appropriate allocation of member services, treatments, and resources • Serve as a resource to Healthfirst’s care management team, members, and outside medical providers • Oversee utilization management functions, including timely authorizations for pre-certification, concurrent review, referrals, and other plan services • Develop and monitor staff goals; provide feedback and coaching; conduct annual performance reviews • Lead by example and foster open communication, teamwork, ownership, and empowered decision-making • Collaborate with medical staff and review medical charts to obtain information for utilization management and solve complex clinical problems • Develop and analyze operational and analytical reports to monitor operational efficiency • Document utilization management activities and decision rationales in electronic medical record systems • Function as a clinical resource for the multidisciplinary care team to maximize patient care quality and manage medical costs • Ensure compliance with CMS, DOH, internal, and other relevant rules • Perform additional duties as assigned

🎯 Exigences

• Associate’s degree • Excellent communication, time management, critical thinking, and problem solving skills • Supervisory, training, or management experience • Experience in managed care, case management, identifying alternative care options, and discharge planning across a variety of treatment settings for high risk, complex populations • Certified Case Manager • Knowledge of InterQual, Milliman, and/or TruCare • Knowledge of CMS, NYSDOH, or MLTCP regulations governing medical management in managed care • Intermediate skills in Microsoft Word, Excel, Outlook, PowerPoint, Access, Adobe, Visio, and Project • Familiarity with PHI systems • Work experience in managed care or healthcare industry in utilization management, including preauthorization of outpatient or inpatient services • Knowledge of utilization management/quality management case philosophies and reporting requirements to NY state and federal agencies • Ability to allocate, monitor, and control resources while delegating and monitoring workloads • Ability to work in a fast-paced environment while building and enhancing team productivity • Demonstrated professionalism and leadership skills, along with the ability to develop, direct, and support staff • RN or LPN clinical license (preferred) • Master’s degree in a related discipline (preferred)

🏖️ Avantages

• Medical, dental, and vision coverage • Incentive and recognition programs • Life insurance • 401k contributions • Competitive compensation and benefits package