Clinical Utilization Management Lead

Healthfirst; Pennsylvania; On-site; USD 89,000 - 132,000; Full time

Benefits offered by this job

Medical insurance

Dental and vision coverage

401k contributions

Incentive programs

Job summary

Healthfirst in Pennsylvania seeks a Manager of Utilization Management to lead Case Management teams and oversee pre-certifications, concurrent reviews, referrals, and resource allocation for high-quality, cost-effective member care.

You will collaborate with medical staff, document decisions in EMR systems, and coach staff to improve performance. The role requires strong leadership, regulatory awareness, and the ability to manage complex cases in a fast-paced environment.

Qualifications

• Associate’s degree required.
• RN or LPN license preferred in related fields.
• Masters degree preferred in related discipline.

Responsibilities

• Oversees utilization management functions including pre-certifications, concurrent review, referrals, and plan services.
• Develops and monitors staff goals; provides coaching; conducts performance reviews; promotes teamwork and ownership.
• Collaborates with medical staff; reviews charts to gather information for utilization management and complex cases.
• Develops and analyzes reports to monitor efficiency and operations.
• Documents utilization management activities and rationale in EMR systems.
• Serves as a clinical resource to maximize patient care while managing medical costs.
• Performs additional duties as assigned.

Skills

Leadership

Communication

Problem solving

Time management

Team training

Managed care

Analytical skills

Regulatory knowledge

Staff development

Clinical collaboration

Education

Associates degree

Job description

Healthfirst in Pennsylvania seeks a Manager of Utilization Management to lead Case Management teams and oversee pre-certifications, concurrent reviews, referrals, and resource allocation for high-quality, cost-effective member care.

You will collaborate with medical staff, document decisions in EMR systems, and coach staff to improve performance. The role requires strong leadership, regulatory awareness, and the ability to manage complex cases in a fast-paced environment.