Senior Utilization Management Case Manager

Healthfirst; Tennessee; On-site; USD 73,000 - 120,000; Full time

Benefits offered by this job

Medical, Dental, Vision

401k contributions

Life Insurance

Job summary

Healthfirst in New York is seeking a Case Manager, Utilization Management to coordinate care plans, conduct pre-certifications, concurrent reviews, discharge planning, and overall utilization for assigned members.

You will document decisions, advocate for beneficiaries, and ensure adherence to InterQual/MCG, CMS, and NYSDOH guidelines while managing caseloads and meeting performance metrics.

Qualifications

• RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT or ST licensure required for medical case management.
• NYS RN or Licensed Social Worker (LCSW/LMSW) for episodic utilization/case management.
• 3 years of experience in mental/behavioral health or addictions settings for behavioral health case management.
• CASAC credential required for CASAC positions.

Responsibilities

• Coordinate case management for assigned member caseloads including pre-certification and reviews.
• Assess medical, psychological, and social issues needing intervention.
• Coordinate treatment with PCPs and providers; document determinations and communications.
• Advocate and educate beneficiaries on services and self-management.
• Develop care plans aligned with physician plans and monitor performance metrics.

Skills

Clinical case management

Communication

Regulatory knowledge

Leadership

Documentation

Education

RN license

LMSW/LCSW

Masters degree preferred

Tools

Outlook

Word

Excel

PowerPoint

Adobe Acrobat

Job description

Healthfirst in New York is seeking a Case Manager, Utilization Management to coordinate care plans, conduct pre-certifications, concurrent reviews, discharge planning, and overall utilization for assigned members.

You will document decisions, advocate for beneficiaries, and ensure adherence to InterQual/MCG, CMS, and NYSDOH guidelines while managing caseloads and meeting performance metrics.