Clinical Utilization Management Lead

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

Job summary

Healthfirst seeks a Manager of Utilization Management to lead Case Management teams, ensuring high-quality, cost-effective care. You will oversee pre-certifications, reviews, referrals, and resource allocation while guiding staff and collaborating with medical leadership.

The role requires a clinical background with strong communication and supervisory experience, plus proficiency in SMIS tools and regulatory awareness. Healthfirst values teamwork and accountability.

Qualifications

• Minimum qualification: Associate’s degree.
• RN or LPN clinical license preferred.
• Master’s degree in a related discipline preferred.
• Strong communication, time management, critical thinking, and problem solving skills.
• Supervisory, training, or management experience preferred.
• Experience in managed care, case management, discharge planning across varied settings for high-risk populations.
• CMS/DOH or NYSDOH/MLTCP knowledge beneficial.

Responsibilities

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

Skills

Staff supervision

Leadership

Critical thinking

Problem solving

Communication

Time management

Education

Associate’s degree

Master’s degree

Tools

Interqual

Milliman

TruCare

Microsoft Word

Microsoft Excel

Microsoft Outlook

PowerPoint

Access

Adobe

Visio

Project

Job description

Healthfirst seeks a Manager of Utilization Management to lead Case Management teams, ensuring high-quality, cost-effective care. You will oversee pre-certifications, reviews, referrals, and resource allocation while guiding staff and collaborating with medical leadership.

The role requires a clinical background with strong communication and supervisory experience, plus proficiency in SMIS tools and regulatory awareness. Healthfirst values teamwork and accountability.