UM Case Manager

Avature; New Jersey; Remote; USD 71,000 - 117,000; Full time

Job summary

An established industry player is seeking a Case Manager for Utilization Management to coordinate care plans and ensure optimal health outcomes for members. This fully remote position involves conducting pre-certifications, assessments, and collaborating with healthcare providers to facilitate treatment. The ideal candidate will possess strong critical thinking and assessment skills, along with relevant licenses and experience in managed care. Join a forward-thinking organization that values quality care and offers a comprehensive benefits package, making a significant impact on member health and service utilization.

Benefits

Medical Coverage

Dental Coverage

Vision Coverage

Life Insurance

401k Contributions

Incentive Programs

Recognition Programs

Qualifications

• Must hold relevant nursing or therapy licenses.
• Experience in managed care and case management is preferred.

Responsibilities

• Coordinates care plans and conducts pre-certification and concurrent reviews.
• Partners with providers for treatment coordination and service authorizations.

Skills

Critical Thinking

Assessment Skills

Case Management

Communication Skills

Education

RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, ST license

Master’s degree in a related discipline

Tools

Interqual

Milliman

Job description

The Case Manager, Utilization Management coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned. The Case Manager, Utilization Management is also responsible for efficient utilization of health services and optimal health outcomes for members, as well as meeting designated quality metrics.

**This position is 100% Remote

Duties/Responsibilities:

• Provides case management services for assigned member caseloads which includes:
• Pre-certification – performing risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments and service utilizations based on clinical documentation, regulatory, and InterQual/MCG criteria
• Assessment - identifying medical, psychological, and social issues that need intervention.
• Coordination - partnering with PCP and other medical providers to coordinate treatments, collateral services, and service authorizations. Negotiates rates with non-partner providers, where applicable. Ensures appropriate access and utilization of a full continuum of network and community resources to support health and recovery
• Documenting - documenting all determinations, notifications, interventions, and telephone encounters in accordance with established documentation standards and regulatory guidelines.
• Reports and escalates questionable healthcare services
• Meets performance metric requirements as part of annual performance appraisals
• Monitors assigned case load to meet performance metric requirements
• Functions as a clinical resource for the multi-disciplinary care team in order to maximize HF member care quality while achieving effective medical cost management
• Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments
• Occasional overtime as necessary
• Additional duties as assigned

Minimum Qualifications:
· RN, LPN, LMSW, LMHC,LMFT, LCSW, PT, OT, and/or ST license
· For CASAC positions only: Credentialed Alcohol and Substance Abuse Counselor
Preferred Qualifications:

• Master’s degree in a related discipline
• Experience in managed care, case management, identifying alternative care options, and discharge planning
• Certified Case Manager
• Interqual and/or Milliman knowledge
• Knowledge of Centers for Medicare & Medicaid Services (CMS) or New York State Department of Health (NYSDOH) regulations governing medical management in managed care
• Relevant clinical work experience
• Demonstrated critical thinking and assessment skills to ensure member care plans are followed.
• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
• Demonstrated professional writing, electronic documentation, and assessment skills.

Hiring Range*:

Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480

All Other Locations (within approved locations): $71,594 - $106,080

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

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.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [e-mail] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights