Senior Manager, Utilization & Care 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

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.