Clinical Utilization Management Lead

HealthFirst; Williamstown (NJ); Sur place; USD 89 000 - 149 000; Plein temps

Résumé du poste

Healthfirst is seeking a Manager of Utilization Management to oversee Case Management teams and ensure high-quality, cost-effective member services and care. The role guides approvals, pre-certifications, and referrals while supporting the care management team and providers.

The position requires strong leadership, clinical licensure preference, and expertise in managed care regulations. It offers growth within a fast-paced healthcare environment with comprehensive benefits.

Qualifications

• Associate’s degree required.
• RN or LPN clinical license preferred; master’s degree in a related discipline preferred.

Responsabilités

• Oversees utilization management functions including timely authorizations related to pre-certification, concurrent review, referrals, and other plan services.
• Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions.
• Collaborates with medical staff and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems.
• Develops and analyzes operational and analytical reports to monitor and track operational efficiency.
• Properly documents utilization management activities and rationale for all decisions in electronic medical records systems.
• Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management.
• Additional duties as assigned.

Connaissances

Communication skills

Time management

Critical thinking

Problem solving

Leadership

Staff supervision

Team collaboration

Resource management

Fast-paced environment adaptability

Formation

Associate’s degree

RN or LPN clinical license

Master’s degree

Outils

InterQual

Milliman

TruCare

Microsoft Word

Microsoft Excel

Microsoft Outlook

PowerPoint

Access

Adobe

Visio

Project

Description du poste

Healthfirst is seeking a Manager of Utilization Management to oversee Case Management teams and ensure high-quality, cost-effective member services and care. The role guides approvals, pre-certifications, and referrals while supporting the care management team and providers.

The position requires strong leadership, clinical licensure preference, and expertise in managed care regulations. It offers growth within a fast-paced healthcare environment with comprehensive benefits.