Manager, Clinical Utilization Management

HealthFirst; Lorida (FL); On-site; USD 103,000 - 149,000; Full time

Job summary

HealthFirst is seeking a Manager of Utilization Management to oversee case management teams and ensure high-quality, cost-effective member care. You will coordinate pre-certifications, reviews, and referrals, while guiding the care team and ensuring regulatory compliance across CMS/NYSDOH frameworks.

Responsibilities include documenting decisions in EMR, coaching staff, and collaborating with medical providers to optimize patient outcomes and resource use.

Qualifications

• Experience in managed care and case management for high-risk populations.
• Knowledge of CMS/NYSDOH/MLTCP regulations.
• Proficient in MS Word, Excel, Outlook, PowerPoint, Access, Adobe, Visio, and Project.
• Ability to allocate and monitor resources and workloads.
• Ability to work in a fast-paced environment.
• Supervisory or management experience.
• Experience with preauthorization of outpatient/inpatient services.

Responsibilities

• Oversees utilization management functions including timely authorizations.
• Provides coaching; conducts annual performance reviews; collaborates with medical staff.
• Documents utilization management activities and rationale in EMR.
• Functions as a clinical resource for the multi-disciplinary care team to maximize care quality and manage costs.
• Demonstrates excellent communication, time management, critical thinking, and problem solving.

Skills

Supervisory/Management

Managed care

CMS NYSDOH regs

MS Office Suite

Utilization management

QA reporting to agencies

Resource allocation

Fast-paced environment

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.
• Provides ongoing feedback and coaching; conducts annual performance reviews; Collaborates with medical staff and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems
• 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
• Excellent communication, time management, critical thinking, and problem solving skills.

Qualifications

• 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
• 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.
• 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

Compliance & Regulatory Responsibilities

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

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 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.

Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430

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).