Clinical Case Manager — Utilization Management II

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

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.