Clinical Utilization Management Lead

HealthFirst; Elm (PA); On-site; USD 89,000 - 149,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

401k contributions

Competitive compensation package

Job summary

Healthfirst is seeking a Manager of Utilization Management to oversee case management teams, ensuring high-quality, cost-effective patient care. The role partners with care teams and providers to optimize utilization, pre-certifications, and reviews, while coaching staff and driving performance metrics.

The manager collaborates with medical staff to resolve complex clinical issues, creates operational reports, and ensures regulatory compliance with CMS and NY regulations.

Qualifications

• Associate degree required; RN or LPN license preferred.
• Master’s degree preferred; strong leadership and communication skills.
• Experience in managed care, case management, and discharge planning.
• Knowledge of Interqual, Milliman or TruCare systems.
• Proficiency with MS Word, Excel, Outlook, PowerPoint, Access.

Responsibilities

• Oversee utilization management functions including pre-certification, concurrent review, and referrals.
• Develop and monitor staff goals; provide coaching and performance reviews.
• Collaborate with medical staff to gather information for complex cases.
• Develop and analyze reports to monitor operational efficiency.
• Document utilization management activities and rationale in EMR.

Skills

Leadership

Communication

Coaching

Problem solving

Team management

Education

Associate’s degree

RN/LPN license (preferred)

Master’s degree (preferred)

Tools

Interqual

Milliman

TruCare

Microsoft Office suite

Job description

Healthfirst is seeking a Manager of Utilization Management to oversee case management teams, ensuring high-quality, cost-effective patient care. The role partners with care teams and providers to optimize utilization, pre-certifications, and reviews, while coaching staff and driving performance metrics.

The manager collaborates with medical staff to resolve complex clinical issues, creates operational reports, and ensures regulatory compliance with CMS and NY regulations.