Clinical Utilization Management Lead

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

401k plan

Job summary

Healthfirst seeks a Manager of Utilization Management to provide daily oversight for Case Management teams, including RNs, social workers, and coordinators. The role ensures high quality, cost-effective allocation of member services, treatments, and resources and serves as a clinical resource to the care management team, members, and outside providers.

Responsibilities include overseeing pre-certification, concurrent review, and referrals; coaching staff; conducting annual reviews; documenting

Qualifications

• Associate’s degree required.
• RN or LPN license preferred.
• Master’s degree in a related discipline preferred.
• Strong communication, time management, critical thinking, and problem solving skills.
• Supervisory or management experience.
• Experience in managed care or case management and discharge planning.

Responsibilities

• Oversees utilization management functions including pre-certification, concurrent review, referrals, and other plan services.
• Develops and monitors goals for staff; provides coaching; conducts annual reviews; promotes teamwork.
• Collaborates with medical staff and reviews medical charts to gather information for UM decisions.
• Develops and analyzes reports to monitor operational efficiency.
• Documents utilization management activities and rationale in EMR.
• Acts as clinical resource for care team to maximize patient care while controlling costs.
• Additional duties as assigned.

Skills

Communication

Time management

Critical thinking

Problem solving

Leadership

Teamwork

Decision making

Analytical thinking

Education

Associate’s degree

Tools

Microsoft Word

Excel

Outlook

PowerPoint

Access

Adobe

Visio

Project

Job description

Healthfirst seeks a Manager of Utilization Management to provide daily oversight for Case Management teams, including RNs, social workers, and coordinators. The role ensures high quality, cost-effective allocation of member services, treatments, and resources and serves as a clinical resource to the care management team, members, and outside providers.

Responsibilities include overseeing pre-certification, concurrent review, and referrals; coaching staff; conducting annual reviews; documenting