Utilization Management Case Manager II - Care Coordination

Healthfirst; Town of Florida (NY); On-site; USD 83,000 - 120,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Life insurance

401(k) contribution

Job summary

Healthfirst seeks a Case Manager, Utilization Management to coordinate care plans and oversee pre-certification and concurrent reviews. You will collaborate with PCPs, document all actions, and advocate for beneficiaries to ensure appropriate utilization and outcomes.

The role emphasizes meeting quality metrics, supporting a full care continuum, and providing education on services and benefits. Strong regulatory knowledge and nursing or social work licensure are required.

Qualifications

• Must hold relevant clinical license as noted in the Minimum Qualifications.
• Experience in medical management, case management, discharge planning or managed care preferred.
• Strong written communication and documentation skills required.

Responsibilities

• Coordinate care plans aligned with physician treatment plans.
• Perform pre-certification, concurrent and retrospective reviews per criteria.
• Advocate and educate beneficiaries on services and benefits.
• Collaborate with PCPs and providers to authorize services.
• Document all determinations and contacts per standards.
• Meet performance metrics and monitor caseloads.

Skills

Clinical case management

Interdisciplinary collaboration

Regulatory knowledge

Documentation

Negotiation

Education

RN/LPN/LMSW/LMHC/LMFT/LCSW/LPT/OT/ST license

NYS RN or LCSW/LMSW (for episodic/utilization)

Tools

InterQual/Milliman knowledge

Job description

Healthfirst seeks a Case Manager, Utilization Management to coordinate care plans and oversee pre-certification and concurrent reviews. You will collaborate with PCPs, document all actions, and advocate for beneficiaries to ensure appropriate utilization and outcomes.

The role emphasizes meeting quality metrics, supporting a full care continuum, and providing education on services and benefits. Strong regulatory knowledge and nursing or social work licensure are required.