Care-Driven Utilization Manager — Case Coordination

Healthfirst; Connecticut; On-site; USD 83,000 - 120,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Incentive and recognition programs

Life insurance

401k contributions

Job summary

Healthfirst is seeking a Case Manager in Utilization Management to coordinate care plans, perform pre-certification and concurrent reviews, and support discharge planning. The role collaborates with PCPs and providers to ensure appropriate utilization of services and alignment with clinical goals.

Qualifications include RN, LPN, LMSW, LMHC, LMFT, or LCSW licensure and health care management experience, with knowledge of InterQual/Milliman criteria and CMS/NYSDOH regulations.

Qualifications

• RN, LPN, LMSW, LMHC,LMFT, LCSW, PT, OT, and/or ST license
• For Episodic Utilization/Case Management: NYS RN or LCSW/LMSW any state
• RN, LPN, LMSW, LMHC,LMFT, LCSW required for Behavioral Health Case Management
• 3 years of work experience in a mental/behavioral health or addictions setting
• For CASAC positions only: Credentialed Alcohol and Substance Abuse Counselor
• Master’s degree in a related discipline
• Experience in managed care, case management, identifying alternative care options, and discharge planning
• Certified Case Manager
• InterQual and/or Milliman knowledge
• Knowledge of CMS or NYSDOH regulations governing medical management in managed care
• Relevant clinical work experience
• Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills
• Demonstrated critical thinking and assessment skills to ensure member care plans are followed
• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
• Demonstrated professional writing, electronic documentation, and assessment skills

Responsibilities

• Provides case management services for assigned member caseloads including pre-certification and retrospective reviews.
• Assessment to identify medical, psychological, and social issues needing intervention.
• Coordination with PCP and providers to coordinate treatments and authorizations.
• Documenting all determinations, notifications, interventions, and encounters per standards.
• Advocates, informs, and educates beneficiaries on services and self-management.
• Develops and executes care plans aligned with physician treatment plans.
• Reports and escalates questionable healthcare services.
• Meets performance metric requirements as part of annual appraisals.
• Monitors caseload to meet metrics and acts as a clinical resource to the care team.
• Identifies opportunities for alternative care options based on assessments.

Skills

InterQual knowledge

Milliman knowledge

Outlook

Word

Excel

PowerPoint

Adobe Acrobat

Critical thinking

Assessment skills

Caseload management

Documentation

Education

RN, LPN, LMSW, LMHC,LMFT, LCSW, PT, OT, and/or ST license

NYS RN or Licensed Social Worker (LCSW/LMSW any state) license

Tools

Outlook

Word

Excel

PowerPoint

Adobe Acrobat

Job description

Healthfirst is seeking a Case Manager in Utilization Management to coordinate care plans, perform pre-certification and concurrent reviews, and support discharge planning. The role collaborates with PCPs and providers to ensure appropriate utilization of services and alignment with clinical goals.

Qualifications include RN, LPN, LMSW, LMHC, LMFT, or LCSW licensure and health care management experience, with knowledge of InterQual/Milliman criteria and CMS/NYSDOH regulations.