Clinical Utilization & Care Management Lead

HealthFirst; Lorida (FL); On-site; USD 103,000 - 149,000; Full time

Job summary

HealthFirst is seeking a Manager of Utilization Management to oversee case management teams and ensure high-quality, cost-effective member care. You will coordinate pre-certifications, reviews, and referrals, while guiding the care team and ensuring regulatory compliance across CMS/NYSDOH frameworks.

Responsibilities include documenting decisions in EMR, coaching staff, and collaborating with medical providers to optimize patient outcomes and resource use.

Qualifications

• Experience in managed care and case management for high-risk populations.
• Knowledge of CMS/NYSDOH/MLTCP regulations.
• Proficient in MS Word, Excel, Outlook, PowerPoint, Access, Adobe, Visio, and Project.
• Ability to allocate and monitor resources and workloads.
• Ability to work in a fast-paced environment.
• Supervisory or management experience.
• Experience with preauthorization of outpatient/inpatient services.

Responsibilities

• Oversees utilization management functions including timely authorizations.
• Provides coaching; conducts annual performance reviews; collaborates with medical staff.
• Documents utilization management activities and rationale in EMR.
• Functions as a clinical resource for the multi-disciplinary care team to maximize care quality and manage costs.
• Demonstrates excellent communication, time management, critical thinking, and problem solving.

Skills

Supervisory/Management

Managed care

CMS NYSDOH regs

MS Office Suite

Utilization management

QA reporting to agencies

Resource allocation

Fast-paced environment

Tools

Word

Excel

Outlook

PowerPoint

Access

Adobe

Visio

Project

Job description

HealthFirst is seeking a Manager of Utilization Management to oversee case management teams and ensure high-quality, cost-effective member care. You will coordinate pre-certifications, reviews, and referrals, while guiding the care team and ensuring regulatory compliance across CMS/NYSDOH frameworks.

Responsibilities include documenting decisions in EMR, coaching staff, and collaborating with medical providers to optimize patient outcomes and resource use.