Manager, Clinical Utilization & Care Management

HealthFirst; East Windsor Hill (CT); On-site; USD 89,000 - 149,000; Full time

Job summary

Healthfirst seeks a Manager of Utilization Management to oversee Case Management teams, ensuring high-quality, cost-efficient member care. You will guide pre-certifications, reviews, referrals and related services while collaborating with medical staff and providers.

You will coach staff, develop performance metrics, and ensure accurate documentation in EMR systems, maintaining strong regulatory compliance and quality outcomes.

Qualifications

• Associate’s degree required.
• RN or LPN clinical license preferred.
• Master’s degree in a related discipline preferred.
• Excellent communication, time management, critical thinking and problem solving skills expected.
• Supervisory, training or management experience preferred.
• Experience in managed care, case management, discharge planning across varied settings for high-risk populations preferred.
• Certified Case Manager and Interqual/Milliman/TruCare knowledge desirable.
• Familiarity with CMS/NYSDOH/MLTCP regulations.
• Proficiency with MS Office suite, Adobe, Visio and Project.

Responsibilities

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

Skills

Communication

Time management

Critical thinking

Problem solving

Supervisory experience

Management experience

Team leadership

Education

Associate’s degree

Master’s degree in a related discipline

RN or LPN clinical license

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

PowerPoint

Access

Adobe

Visio

Project

PHI systems

Job description

Healthfirst seeks a Manager of Utilization Management to oversee Case Management teams, ensuring high-quality, cost-efficient member care. You will guide pre-certifications, reviews, referrals and related services while collaborating with medical staff and providers.

You will coach staff, develop performance metrics, and ensure accurate documentation in EMR systems, maintaining strong regulatory compliance and quality outcomes.