Case Manager - Utilization Management II-1

healthfirst; United States; On-site; USD 70,000 - 95,000; Full time

Job summary

Healthfirst seeks a skilled Case Manager, Utilization Management, to coordinate care plans, perform pre-certifications and concurrent reviews, and collaborate with providers to maximize quality outcomes and efficient use of health services.

You will document determinations, educate beneficiaries, and support discharge planning while meeting performance metrics and compliance standards.

Qualifications

• Experience in case management within mental/behavioral health or addictions.
• Knowledge of InterQual/Malliman criteria and care-utilization review.
• Ability to document and communicate effectively across clinical teams.

Responsibilities

• Coordinate case management for assigned members and conduct pre-certifications and reviews.
• Identify medical, psychological, and social needs requiring intervention.
• Collaborate with PCPs and providers to coordinate treatments and authorizations.

Skills

Case management

Critical thinking

Documentation

Communication

Education

RN/LPN/LMSW/LMHC/LMFT/LCSW/LPT/OT/ST license

Tools

InterQual

Milliman

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.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

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