Utilization Management Case Manager II

Healthfirst; Town of Texas (WI); On-site; USD 73,000 - 120,000; Full time

Benefits offered by this job

Medical coverage

Dental and vision coverage

401(k) contributions

Incentive programs

Life insurance

Job summary

Healthfirst is seeking a Case Manager, Utilization Management to coordinate care plans for assigned members, conduct pre-certification, concurrent review, and discharge planning. You will collaborate with PCPs and providers to ensure appropriate utilization and high-quality outcomes.

Responsibilities include documentation, advocacy, and developing care plans aligned with physicians' treatment goals, with performance metrics and opportunities to optimize costs. Overtime may be required.

Qualifications

• Must hold applicable clinical license(s) such as RN/LPN/LMSW/LMHC/LMFT/LCSW.
• Experience in managed care, case management, discharge planning, or related field preferred.
• Strong documentation and regulatory compliance skills.

Responsibilities

• Coordinate case management for assigned member caseloads.
• Perform pre-certification and concurrent reviews using clinical criteria.
• Collaborate with PCPs and providers to coordinate treatments and services.
• Document all determinations and communications in accordance with standards.
• Advise and educate members on services and health benefits.
• Develop and execute care plans aligned with treatment goals.
• Meet performance metrics and monitor caseloads.
• Support alternative care options where appropriate.
• Possible overtime as needed.

Skills

Critical thinking

Assessment skills

Documentation

Interpersonal skills

Education

RN license

LPN license

LMSW license

LMHC license

LMFT license

LCSW license

PT license

OT license

ST license

Tools

InterQual/Milliman knowledge

Job description

Healthfirst is seeking a Case Manager, Utilization Management to coordinate care plans for assigned members, conduct pre-certification, concurrent review, and discharge planning. You will collaborate with PCPs and providers to ensure appropriate utilization and high-quality outcomes.

Responsibilities include documentation, advocacy, and developing care plans aligned with physicians' treatment goals, with performance metrics and opportunities to optimize costs. Overtime may be required.