Manager, Clinical Utilization Management

HealthFirst; Little Elm (TX); On-site; USD 89,000 - 132,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Incentive programs

Life insurance

401k contributions

Job summary

Healthfirst seeks a Manager of Utilization Management to oversee Case Management teams including RNs, Social Workers, and Coordinators. The role ensures high-quality, cost-effective allocation of member services and resources, serving as a clinical resource to the care team and outside providers.

Responsibilities include managing pre-certifications and reviews, coaching staff, and generating operational reports while ensuring CMS/DOH compliance.

Qualifications

• Associate’s degree required for the role.
• RN or LPN license preferred to support clinical oversight.
• Master’s degree in a related discipline preferred.
• Certified Case Manager certification is advantageous.
• Experience in managed care, case management, and discharge planning.

Responsibilities

• Oversees utilization management functions including precertifications and referrals.
• Develops and monitors staff goals and conducts performance reviews.
• Collaborates with medical staff to obtain information for complex cases.
• Develops reports to monitor operational efficiency and cost management.
• Documents utilization management activities in EMR systems.
• Provides clinical resource support to the multi-disciplinary team.

Skills

Communication

Time management

Critical thinking

Problem solving

Education

Associate’s degree

RN or LPN license

Master’s degree in related discipline

Certified Case Manager

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

PowerPoint

Microsoft 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 workloadsAbility to work in a fast-paced environment while building and enhancing team productivityDemonstrated professionalism and leadership skills along with the ability to develop, direct, and support staffCompliance & Regulatory Responsibilities:

Compliance & Regulatory Responsibilities

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

Equal Opportunity Employer

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.

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

Benefits

• Medical coverage.
• Dental coverage.
• Vision coverage.
• Incentive and recognition programs.
• Life insurance.
• 401k contributions (all benefits are subject to eligibility requirements).

Additional Compensation and Benefits

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.