Manager, Clinical Utilization Management

🔥 7 minutes ago

🦌 Connecticut, Florida, +3 more states – Remote

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

💵 $88.7k - $149.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

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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

• 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

🎯 Requirements

• 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)

🏖️ Benefits

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