Manager, Clinical Utilization Management

HealthFirst; Philadelphia (Philadelphia County); On-site; USD 89,000 - 149,000; Full time

Job summary

Healthfirst is seeking a Manager of Utilization Management to lead Case Management teams (RN, social workers, coordinators) and ensure high-quality, cost-effective utilization of member services, treatments, and resources.

The role partners with medical staff and outside providers, overseeing pre-certifications, reviews, and referrals while guiding performance and staff development in a fast-paced managed care setting.

Qualifications

• Associate’s degree required.
• RN or LPN clinical license preferred.
• Master’s degree preferred.
• Excellent communication, time management, critical thinking and problem solving skills.
• Supervisory, training or management experience.
• Experience in managed care, case management, discharge planning across settings for high risk populations.
• Certified Case Manager.
• Knowledge of Interqual, Milliman, and TruCare.
• Knowledge of CMS/NYSDOH/MLTCP regulations governing medical management in managed care.
• MS Word, Excel, Outlook, PowerPoint, Access, Adobe, Visio and Project skills.
• PHI systems familiarity.
• Experience in utilization management including preauthorization of outpatient or inpatient services.
• Knowledge of utilization management/quality management philosophies and reporting requirements.

Responsibilities

• Oversees utilization management functions including timely authorizations for pre-certification, concurrent review, referrals and other plan services.
• Develops and monitors goals for staff; provides feedback and conducts performance reviews; fosters teamwork and empowerment.
• Collaborates with medical staff and reviews charts to obtain information for utilization management and complex clinical problems.
• Develops and analyzes reports to monitor operational efficiency.
• Documents utilization management activities and rationale in EMR systems.
• Acts as clinical resource for multidisciplinary care teams to maximize patient care and control costs.
• Performs additional duties as assigned.

Skills

Communication skills

Time management

Critical thinking

Problem solving

Supervisory/Management experience

Discharge planning

Managed care knowledge

Interqual/Milliman/TruCare knowledge

CMS/NYSDOH/MLTCP knowledge

MS Office proficiency

PHI systems familiarity

Education

Associate’s degree

RN or LPN clinical license

Master’s degree in related discipline

Certified Case Manager

Tools

Microsoft 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.

• 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.

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.

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): $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.