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
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.
Know Your Rights
Benefits
Health insurance
Additional Information
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
Healthfirst · NY