Clinical Utilization Management Lead

Healthfirst; Florida; Sur place; USD 89 000 - 149 000; Plein temps

Résumé du poste

Healthfirst is seeking a Manager of Utilization Management to lead Case Management teams, ensuring high-quality, cost-efficient allocation of member services and resources. You will serve as a clinical resource for the care team and collaborate with providers to resolve complex cases.

The role focuses on oversight of pre-certification, concurrent review, and documentation in EMR systems, with emphasis on leadership, analytics, and regulatory compliance.

Qualifications

• Associate’s degree
• RN or LPN license
• Master’s degree in a related discipline
• Certified Case Manager
• Interqual, Milliman, and/or TruCare knowledge
• Knowledge of CMS/NYSDOH or regulatory requirements
• Strong leadership and communication skills

Responsabilités

• Oversees utilization management functions including pre-certification and concurrent review.
• Develops and monitors staff goals; provides coaching and performance reviews.
• Collaborates with medical staff to obtain information for utilization management and resolve complex cases.
• Develops and analyzes operational reports to monitor efficiency.
• Documents activities and rationale in EMR systems.
• Leads multidisciplinary care team to maximize patient care and cost effectiveness.

Connaissances

Communication

Time management

Critical thinking

Problem solving

Supervisory experience

Management experience

Discharge planning

CMS/NYSDOH knowledge

PHI systems familiarity

Team leadership

Formation

Associate's degree

RN or LPN license

Master’s degree in related discipline

Certified Case Manager

Outils

Word

Excel

Outlook

PowerPoint

Access

Adobe

Visio

Project

Description du poste

Healthfirst is seeking a Manager of Utilization Management to lead Case Management teams, ensuring high-quality, cost-efficient allocation of member services and resources. You will serve as a clinical resource for the care team and collaborate with providers to resolve complex cases.

The role focuses on oversight of pre-certification, concurrent review, and documentation in EMR systems, with emphasis on leadership, analytics, and regulatory compliance.