Clinical Utilization Management Lead

Healthfirst; New York (NY); Hybrid; USD 103,000 - 149,000; Full time

Benefits offered by this job

Health benefits

Job summary

Healthfirst in New York City area seeks a Manager of Utilization Management to oversee case management teams, ensuring high-quality, cost-effective utilization of member services and resources. You will collaborate with medical staff and evaluate charts for appropriate UM decisions, while developing reporting dashboards and coaching staff.

The role requires an Associate’s degree (RN/LPN license and Master’s degree preferred), strong communication, and regulatory knowledge.

Qualifications

• Associate’s degree is required
• RN or LPN license preferred
• Master’s degree preferred
• Excellent communication, time management, critical thinking and problem solving skills
• Supervisory or management experience
• Experience in managed care, case management, discharge planning across high risk populations
• Certified Case Manager or CMS/NYSDOH knowledge is a plus
• Knowledge of InterQual, Milliman and TruCare systems
• MS Word, Excel, Outlook, PowerPoint, Access, Adobe, Visio and Project skills
• Familiarity with PHI systems and utilization management in healthcare

Responsibilities

• Oversees utilization management functions including pre-certification, concurrent review, referrals, and services
• Develops and monitors staff goals; provides coaching; conducts annual performance reviews
• Collaborates with medical staff; reviews charts to obtain information for UM decisions
• Develops and analyzes reports to monitor operational efficiency
• Documents UM activities and rationale in EMR systems
• Acts as a clinical resource for the multi-disciplinary care team to maximize quality and manage costs
• Performs additional duties as assigned

Skills

Utilization management

Staff supervision

Communication

Problem solving

Leadership

Data analysis

Education

Associate’s degree

RN or LPN license

Master’s degree

Tools

InterQual

Milliman

TruCare

Microsoft Word

Excel

PowerPoint

Access

PHI systems

Job description

Healthfirst in New York City area seeks a Manager of Utilization Management to oversee case management teams, ensuring high-quality, cost-effective utilization of member services and resources. You will collaborate with medical staff and evaluate charts for appropriate UM decisions, while developing reporting dashboards and coaching staff.

The role requires an Associate’s degree (RN/LPN license and Master’s degree preferred), strong communication, and regulatory knowledge.