Case Manager - Utilization Management II-1

Healthfirst; Pennsylvania; On-site; USD 73,000 - 120,000; Full time

Benefits offered by this job

Competitive salary

Job summary

Healthfirst is seeking a Case Manager, Utilization Management to coordinate care plans, perform pre-certification, and conduct reviews for assigned members. The role emphasizes efficient utilization of services and achieving quality metrics.

The incumbent will partner with PCPs and providers to coordinate treatments, document decisions, and support members with self-management and benefits understanding. Strong clinical assessment skills are essential.

Qualifications

• Minimum Qualifications: RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, and/or ST license; For Episodic Utilization/Case Management: NYS RN or LCSW/LMSW. Behavioral Health: RN, LPN, LMSW, LMHC, LMFT, LCSW; 3 years in mental/behavioral health. CASAC credential may apply.
• Preferred Qualifications: RN; Master’s degree; Managed care/case management experience; InterQual/Milliman knowledge; CMS/NYSDOH regs knowledge; Proficient office software; Strong assessment and reporting skills.

Responsibilities

• Coordinate care plans with providers and facilities.
• Perform risk-identification and reviews to evaluate medical necessity.
• Document determinations and communications per guidelines.
• Advocate and educate beneficiaries on services and benefits.
• Ensure alignment with physician treatment plans and care goals.

Skills

Case management

Clinical coordination

Risk assessment

Documentation

InterQual knowledge

Education

RN license

LCSW/LMSW licensed

Master's degree (preferred)

Tools

Microsoft Office

InterQual/Milliman knowledge

Job description

The Case Manager, Utilization Management coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned. The Case Manager, Utilization Management is also responsible for efficient utilization of health services and optimal health outcomes for members, as well as meeting designated quality metrics.

Duties/Responsibilities

• Provides case management services for assigned member caseloads which includes:
  • Pre-certification – performing risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments and service utilizations based on clinical documentation, regulatory, and InterQual/MCG criteria
  • Assessment - identifying medical, psychological, and social issues that need intervention.
  • Coordination - partnering with PCP and other medical providers to coordinate treatments, collateral services, and service authorizations. Negotiates rates with non-partner providers, where applicable. Ensures appropriate access and utilization of a full continuum of network and community resources to support health and recovery
  • Documenting - documenting all determinations, notifications, interventions, and telephone encounters in accordance with established documentation standards and regulatory guidelines.
  • Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits.
  • Develops and executes on care plans that align with the physician’s treatment plans and recommends interventions that align with proposed goals as needed
  • Reports and escalates questionable healthcare services
  • Meets performance metric requirements as part of annual performance appraisals
  • Monitors assigned case load to meet performance metric requirements
  • Functions as a clinical resource for the multi-disciplinary care team in order to maximize HF member care quality while achieving effective medical cost management
  • Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments
  • Occasional overtime as necessary
  • Additional duties as assigned

Minimum Qualifications

• For Medical Case Management:
  • RN, LPN, LMSW, LMHC,LMFT, LCSW, PT, OT, and/or ST license
  • For Episodic Utilization/Case Management: NYS RN or Licensed Social Worker (LCSW/LMSW any state)
• For Behavioral Health Case Management:
  • RN, LPN, LMSW, LMHC,LMFT, LCSW
  • 3 years of work experience in a mental/behavioral health or addictions setting
  • For CASAC positions only: Credentialed Alcohol and Substance Abuse Counselor

Preferred Qualifications

• Registered Nurse (RN)
• 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 Centers for Medicare & Medicaid Services (CMS) or New York State Department of Health (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.

Hiring Range*

• Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360
• All Other Locations (within approved locations): $73,400 - $108,160

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.

Hiring Range*

• Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360
• All Other Locations (within approved locations): $73,400 - $108,160

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.