Manager, Clinical Utilization Management

healthfirst; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Healthfirst seeks a Manager of Utilization Management to oversee Case Management teams including RNs, social workers, and coordinators. You will ensure high quality, cost-effective allocation of services and act as a resource to care teams and providers.

You will lead utilization management functions, drive performance, and develop reports while ensuring compliance with CMS, NYSDOH, and other regulations. Strong leadership and communication are essential.

Qualifications

• Associate's degree required.
• RN or LPN clinical license preferred.
• Master's degree preferred.
• Experience in managed care or case management desirable.
• Knowledge of CMS/DOH regulations preferred.
• Strong communication and leadership skills.

Responsibilities

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

Skills

Excellent communication

Time management

Critical thinking

Problem solving

Supervisory experience

Team leadership

Ability to work in fast-paced

Education

Associate's degree

RN or LPN clinical license

Master's degree in a related discipline

Tools

Interqual knowledge

Milliman knowledge

TruCare knowledge

Microsoft Word/Excel/Outlook/PowerPoint/Access

Adobe

Visio

Project

PHI systems familiarity

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.

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