Utilization Management Manager

The Manager of Utilization Management provides daily oversight for Case Management teams (which includes RN’s, Social Workers, and Coordinators). The Manager of Utilization Management is responsible for ensuring high quality, cost-effective, and appropriate allocation of member services, treatments, and resources. The Manager of Utilization Management serves as a resource to Healthfirst’s care management team, members, and outside medical providers. Duties/Responsibilities

• Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, referrals, and other plan services
• Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions
• Collaborates with medical staff and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems
• Allocate, monitor, and control resources while delegating and monitoring workloads
• Develops and analyzes operational and analytical reports to monitor and track operational efficiency
• Properly documents utilization management activities and rationale for all decisions in electronic medical records systems
• Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management
• Additional duties as assigned

Minimum Qualifications

• Associate’s degree
• RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license
• Work experience demonstrating verbal and written communication skills
• Experience working independently in a fast-paced environment that requires problem solving skills and handling multiple priorities simultaneously
• Experience with Microsoft Office Suite applications including Excel, Word, Power Point and Outlook

Preferred Qualifications

• RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license
• Master’s degree in a related discipline
• Demonstrated professionalism and leadership skills along with the ability to train, develop, direct, and support staff
• 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
• Interqual, Milliman, and/or TruCare knowledge
• Knowledge of Centers for Medicare & Medicaid Services (CMS), New York State Department of Health (NYSDOH), or MLTCP regulations governing medical management in managed care
• 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.

Compliance & Regulatory Responsibilities: The Manager is responsible for ensuring regulatory compliance with CMS, DOH, internal, and other relevant rules. Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $116,800 - $168,810
• All Other Locations (within approved locations): $99,700 - $148,325

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

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