Senior Clinical Utilization Management Lead

Healthfirst; Texas; 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 in the United States seeks a Manager of Utilization Management to oversee Case Management teams, ensuring high-quality, cost-effective allocation of member services and resources. You will be a clinical resource to the care team, guiding pre-certifications, reviews, and discharge planning to optimize patient outcomes.

The role requires leadership, regulatory knowledge, and experience in managed care.

Qualifications

• Associate’s degree required.
• RN or LPN license preferred.
• Master’s degree preferred.
• Strong communication and management skills.
• Experience in managed care/case management with high-risk populations.

Responsibilities

• Oversees utilization management functions including pre-certification, concurrent review, referrals and other plan services.
• Develops goals for staff, provides coaching, conducts performance reviews and promotes teamwork and ownership.
• Collaborates with medical staff to obtain information for complex clinical decisions.
• Develops and analyzes reports to monitor operational efficiency.
• Documents utilization management activities and rationale in EMR systems.
• Act as a clinical resource to the multi-disciplinary care team to maximize patient care and control costs.
• Other duties as assigned.

Skills

Communication

Time management

Critical thinking

Problem solving

Supervisory experience

PHI systems familiarity

Regulatory knowledge

Education

Associate’s degree

RN or LPN clinical license

Master’s degree in related discipline

Tools

Interqual, Milliman, TruCare

Microsoft Office suite

Job description

Healthfirst in the United States seeks a Manager of Utilization Management to oversee Case Management teams, ensuring high-quality, cost-effective allocation of member services and resources. You will be a clinical resource to the care team, guiding pre-certifications, reviews, and discharge planning to optimize patient outcomes.

The role requires leadership, regulatory knowledge, and experience in managed care.