Manager, Clinical Utilization Management

Healthfirst; Florida; On-site; USD 89,000 - 149,000; Full time

Job summary

Healthfirst is seeking a Manager of Utilization Management to lead Case Management teams, ensuring high-quality, cost-efficient allocation of member services and resources. You will serve as a clinical resource for the care team and collaborate with providers to resolve complex cases.

The role focuses on oversight of pre-certification, concurrent review, and documentation in EMR systems, with emphasis on leadership, analytics, and regulatory compliance.

Qualifications

• Associate’s degree
• RN or LPN license
• Master’s degree in a related discipline
• Certified Case Manager
• Interqual, Milliman, and/or TruCare knowledge
• Knowledge of CMS/NYSDOH or regulatory requirements
• Strong leadership and communication skills

Responsibilities

• Oversees utilization management functions including pre-certification and concurrent review.
• Develops and monitors staff goals; provides coaching and performance reviews.
• Collaborates with medical staff to obtain information for utilization management and resolve complex cases.
• Develops and analyzes operational reports to monitor efficiency.
• Documents activities and rationale in EMR systems.
• Leads multidisciplinary care team to maximize patient care and cost effectiveness.

Skills

Communication

Time management

Critical thinking

Problem solving

Supervisory experience

Management experience

Discharge planning

CMS/NYSDOH knowledge

PHI systems familiarity

Team leadership

Education

Associate's degree

RN or LPN license

Master’s degree in related discipline

Certified Case Manager

Tools

Word

Excel

Outlook

PowerPoint

Access

Adobe

Visio

Project

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.

Responsibilities

• 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
• Additional duties as assigned

Minimum Qualifications

• Associate’s degree

Preferred Qualifications

• RN or LPN clinical license
• Master’s degree in a related discipline
• Excellent communication, time management, critical thinking, and problem solving skills.
• Supervisory, training, or management experience
• Experience in managed care, case management, identifying alternative care options, and discharge planning across a variety of treatment settings for high risk, complex populations
• Certified Case Manager
• Interqual, Milliman, and/or TruCare knowledge
• Knowledge of Centers for Medicare & Medicaid Services (CMS), New York State Department of Health (NYSDOH), or MLTCP regulations governing medical management in managed care
• Intermediate Microsoft Word, Excel, Outlook, Powerpoint, Access, Adobe, Visio, and Project skills.
• Familiarity with PHI systems
• Work experience in managed care or healthcare industry in utilization management including preauthorization of outpatient or inpatient services
• Knowledge of utilization management/quality management case philosophies and reporting requirements to NY state and federal agencies.
• Ability to allocate, monitor, and control resources while delegating and monitoring workloads
• Ability to work in a fast-paced environment while building and enhancing team productivity
• Demonstrated professionalism and leadership skills along with the ability to develop, direct, and support staff

Compliance & Regulatory Responsibilities

The Manager is responsible for ensuring regulatory compliance with CMS, DOH, internal, and other relevant rules.

Hiring Range*

• Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430
• All Other Locations (within approved locations): $88,700 - $131,920

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.