Case Manager – Utilization Management II

🔥 17 hours ago

🦌 Connecticut, Louisiana, +12 more states – Remote

🦌 Connecticut – Remote ⚜️ Louisiana – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌾 North Dakota – Remote 🌪️ Oklahoma – Remote 🎸 Mississippi – Remote 🗿 South Dakota – Remote ⛷️ Utah – Remote 🦬 Wyoming – Remote

💵 $73.4k - $108.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Healthfirst

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1993

🛡️ Insurance

🏥 Healthcare

⚕️ Healthcare Insurance

Insurance • Healthcare • Healthcare Insurance

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.

📋 Description

• Coordinate care plans for assigned members • Conduct pre-certification, concurrent review, discharge planning, and case management • Perform risk identification, preadmission, concurrent, and retrospective reviews for treatment appropriateness and medical necessity using clinical documentation, regulatory, and InterQual/MCG criteria • Identify medical, psychological, and social issues requiring intervention • Partner with PCPs and other medical providers to coordinate treatments, collateral services, and service authorizations • Negotiate rates with non-partner providers where applicable • Ensure access to and utilization of network and community resources • Document determinations, notifications, interventions, and telephone encounters according to standards and regulations • Advocate, inform, and educate beneficiaries on services, self-management techniques, and health benefits • Develop and execute care plans aligned with physician treatment plans • Report and escalate questionable healthcare services • Monitor caseloads and meet performance metrics • Serve as a clinical resource for the multidisciplinary care team to maximize member care quality and manage medical costs • Identify and facilitate alternative care options • Work occasional overtime as necessary • Perform additional assigned duties

🎯 Requirements

• RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, and/or ST license for Medical Case Management • NYS RN or Licensed Social Worker (LCSW/LMSW any state) for Episodic Utilization/Case Management • RN, LPN, LMSW, LMHC, LMFT, or LCSW for Behavioral Health Case Management • 3 years of work experience in a mental/behavioral health or addictions setting • Credentialed Alcohol and Substance Abuse Counselor for CASAC positions only • Registered Nurse (RN) preferred • 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 CMS or NYSDOH regulations governing medical management in managed care preferred • Relevant clinical work experience preferred • Intermediate Outlook, Basic Word, Excel, PowerPoint, and Adobe Acrobat skills preferred • Demonstrated critical thinking and assessment skills • Ability to manage large caseloads and work effectively in a fast-paced environment • Professional writing, electronic documentation, and assessment skills

🏖️ Benefits

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