Strategic Utilization Case Manager II

Healthfirst; New York (NY); On-site; USD 83,000 - 120,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Life insurance

401k

Job summary

Healthfirst is seeking a Case Manager in Utilization Management to coordinate care plans, perform pre-certification, and conduct concurrent reviews for assigned members. The role involves collaboration with PCPs, documenting care actions, and guiding patients on benefits and self-management.

Ideal candidates hold an RN/LPN/LCSW/LMSW/LMHC/LMFT license or equivalent, with experience in managed care and discharge planning; advanced credentials like CASAC are a plus.

Qualifications

• RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, and/or ST license required.
• For Episodic Utilization/Case Management: NYS RN or Licensed Social Worker (LCSW/LMSW) in any state.
• Behavioral Health Case Management: RN, LPN, LMSW, LMHC, LMFT, LCSW; 3 years in mental/behavioral health or addictions setting.
• CASAC credential preferred for CASAC positions only.

Responsibilities

• Coordinate case management services for assigned member caseloads, including pre-certification, concurrent review, and discharge planning.
• Assess medical, psychological, and social issues requiring intervention.
• Partner with PCP and providers to coordinate treatments and service authorizations.
• Document determinations, notifications, interventions, and calls per standards.
• Advocate and educate beneficiaries on services, self-management and health benefits.
• Develop and execute care plans aligned with physicians’ treatment plans and goals.
• Escalate questionable health services and monitor performance metrics.
• Serve as a clinical resource for the care team to maximize member outcomes and control costs.

Skills

RN license

LPN license

LMSW

LMHC

LMFT

LCSW

PT license

OT license

Education

Master’s degree

Tools

InterQual

Milliman

InterQual/Milliman knowledge

MS Office (Outlook, Word, Excel, PowerPoint)

Adobe Acrobat

Job description

Healthfirst is seeking a Case Manager in Utilization Management to coordinate care plans, perform pre-certification, and conduct concurrent reviews for assigned members. The role involves collaboration with PCPs, documenting care actions, and guiding patients on benefits and self-management.

Ideal candidates hold an RN/LPN/LCSW/LMSW/LMHC/LMFT license or equivalent, with experience in managed care and discharge planning; advanced credentials like CASAC are a plus.