Clinical Utilization Review Manager

Healthfirst; New York (NY); Hybrid; USD 117,000 - 169,000; Full time

Job summary

Healthfirst is seeking a Manager of Utilization Management in New York to oversee Case Management teams including RNs, social workers, and coordinators, ensuring quality, cost-effective, and appropriate member care. The role collaborates with medical staff, analyzes utilization data, and maintains documentation in EMR systems while supporting the care management team and external providers.

Candidates should have a clinical license and leadership experience in managed care with strong

Qualifications

• Associate degree or clinical license required; RN/LPN/LMSW/LCSW or equivalent.
• BSN and 5+ years of progressive clinical leadership in managed care preferred.
• CCM/ACM or comparable certification preferred; strong communication and leadership are essential.

Responsibilities

• Oversees utilization management functions including authorizations, pre-certification, and reviews.
• Leads staff development, coaching, and performance reviews to drive quality and teamwork.
• Collaborates with medical staff to obtain information and resolve complex clinical issues.
• Develops and analyzes reports to monitor operational efficiency and utilization trends.
• Documents utilization actions and rationale in EMR systems.
• Acts as a clinical resource to maximize patient care while managing medical costs.

Skills

Communication skills

Problem solving

Multitasking

Education

Associate degree or clinical license

BSN

CCM/ACM certification

Tools

Microsoft Excel

Microsoft Word

PowerPoint

Outlook

Job description

Position Summary

The Manager of Utilization Management provides daily oversight for Case Management teams (which includes RN’s, Social Workers, and Coordinators). The Manager of Utilization Management is responsible for ensuring high quality, cost-effective, and appropriate allocation of member services, treatments, and resources. The Manager of Utilization Management serves as a resource to Healthfirst’s care management team, members, and outside medical providers.

• Oversees utilization management functions which include 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.

Minimum Qualifications

• Associate’s degree RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license
• Work experience demonstrating verbal and written communication skills
• Experience working independently in a fast-paced environment that requires problem solving skills and handling multiple priorities simultaneously
• Experience with Microsoft Office Suite applications including Excel, Word, Power Point and Outlook

Preferred Qualifications

• BSN 5+ years of progressive clinical experience in managed care, LTSS, home health, or community-based care, 3+ years demonstrated leadership experience.
• Strong expertise in New York State Medicaid LTSS and utilization management, with advanced ability to interpret UAS-NY/Community Health Assessment (CHA) findings and translate NYS medical-necessity criteria into consistent, clinically sound, and compliant LTSS determinations.
• Proven experience leading clinical teams, providing oversight of complex and high-risk cases, and driving consistency and quality in utilization decisions.
• Demonstrated ability to monitor clinical and operational performance, identify trends and opportunities for improvement, strengthen workflows and decision-support practices, and ensure regulatory and audit readiness.
• Strong collaboration skills with Medical Directors, Care Management, Appeals, Compliance, Operations, and other key stakeholders.
• CCM, ACM, or comparable certification preferred.

Additional duties as assigned

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.

HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [e-mail] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied.

Thank you for considering a career with HF Management Services, LLC.

Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $116,800 - $168,810 All Other Locations (within approved locations): $99,700 - $148,325

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

Healthfirst is New York’s largest not-for-profit health insurer offering it’s nearly 1.7 million members access to high-quality, affordable healthcare. As part of the community for nearly 30 years, Healthfirst’s unique advantage is rooted in its belief that good health doesn’t start in a doctor’s office. The company’s mission is to put its members first by working closely with care providers and community leaders to address broader issues that can impact health and well‑being. This value-based care model is the foundation of the company’s sustained growth in one of the most dynamic markets in the country.

So, if you are passionate about what you do and want to work for a company that is focused on the future and dedicated to making a difference in people’s lives, then Healthfirst is for you.