Clinical Utilization Management Lead

HealthFirst; Hartford (CT); Presencial; USD 89 000 - 149 000; Tempo integral

Resumo da oferta

Healthfirst in Hartford, CT seeks a Manager of Utilization Management to oversee Case Management teams, ensuring high-quality, cost-effective member care. You will supervise RN/ Social Work staff, coordinate with providers, and drive data-driven improvements across utilization and discharge planning.

The role emphasizes leadership, adherence to CMS/NYSDOH regulations, and collaboration to optimize patient outcomes while controlling medical costs.

Qualificações

• Associate’s degree required.
• RN or LPN clinical license.
• Master’s degree in a related discipline.
• Excellent communication, time management, critical thinking, and problem solving.
• Supervisory or management experience.
• Experience in managed care and case management.
• Certified Case Manager.
• Interqual, Milliman, and TruCare knowledge.
• CMS/NYSDOH/MLTCP regulations knowledge.
• Proficiency with MS Office and related tools.
• Familiarity with PHI systems.
• Experience in utilization management including preauthorization.
• Knowledge of QM/UM philosophies and NY/state/federal reporting.
• Ability to allocate and monitor resources.
• Ability to work in a fast-paced environment.
• Leadership to develop and support staff.

Responsabilidades

• Oversees utilization management functions including pre-certification, concurrent review, referrals, and other plan services.
• Develops and monitors goals for staff; provides ongoing coaching; conducts annual performance reviews; leads by example.
• Collaborates with medical staff and reviews charts to obtain information for UM and complex problems.
• Develops and analyzes operational reports to monitor efficiency.
• Documents UM activities and rationale in EMR.
• Functions as a clinical resource to maximize quality of care while managing costs.
• Additional duties as assigned.

Conhecimentos

Communication skills

Time management

Problem solving

Leadership

Team collaboration

Critical thinking

Documentation

Formação académica

Associate’s degree

RN or LPN license

Master’s degree in a related discipline

Ferramentas

Interqual

Milliman

TruCare

PHI systems

Descrição da oferta de emprego

Healthfirst in Hartford, CT seeks a Manager of Utilization Management to oversee Case Management teams, ensuring high-quality, cost-effective member care. You will supervise RN/ Social Work staff, coordinate with providers, and drive data-driven improvements across utilization and discharge planning.

The role emphasizes leadership, adherence to CMS/NYSDOH regulations, and collaboration to optimize patient outcomes while controlling medical costs.