Utilization & Care Coordination Manager

PROMESA R.H.C.F.; New York (NY); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Job summary

Acacia Network is seeking an Utilization Manager in Bronx, NY, to coordinate pre-authorization with Medicaid/MCOs, review medical necessity, and support discharge planning. You will collaborate with a multidisciplinary team to ensure services meet clinical and financial requirements.

The role requires strong communication with leadership and external providers, plus the ability to manage complex case data and maintain confidentiality across systems.

Qualifications

• Minimum of 2 years of case management and/or utilization review experience.
• Strong problem-solving and advanced analytical skills necessary to read, understand, interpret, and analyze statistical data.
• Excellent oral, written, organizational and interpersonal communication skills.
• Ability to communicate effectively with senior leadership as well as other clinical/nonclinical directors, managers, staff, consultants and MCOs.
• Demonstrated ability to effectively collaborate with peers and senior leadership on project assignments and group presentations.

Responsibilities

• Obtaining the required pre-authorization/certification of specified services from the MCO and communicating end of benefit status and/or reimbursement changes to Finance and others as deemed necessary.
• Conducting ongoing medical necessity reviews, which may be pre-service, concurrent and/or retrospective in nature, by evaluating clinical data and submitting appropriate documentation to update the patient/resident’s status to the MCO as scheduled.
• Acting as a liaison between the residential program and the MCO to better facilitate the reimbursement process.
• Referring MCO denials and non-covered medical services to the directors for appeal determination and next steps
• Conduct medical record reviews of all managed care patients within the first 24 to 72 hours (if admitted on a Friday after 5:00pm) then weekly as required to promote desired clinical and financial outcomes by, but not limited to: meeting with all managed care residents/patients to better assist in the selection of appropriate provider resources and identification of quality and cost-effective services throughout the continuum of care.
• Acting as a resource to the interdisciplinary team regarding MCO requirements for admission, continued stay and discharge planning.
• Providing early identification of covered care and ensuring that claims are approved when the requirements are met.

Skills

Problem solving

Analytical thinking

Communication skills

Team collaboration

Leadership

Tools

MS Word

MS Excel

Job description

Acacia Network is seeking an Utilization Manager in Bronx, NY, to coordinate pre-authorization with Medicaid/MCOs, review medical necessity, and support discharge planning. You will collaborate with a multidisciplinary team to ensure services meet clinical and financial requirements.

The role requires strong communication with leadership and external providers, plus the ability to manage complex case data and maintain confidentiality across systems.