Utilization Management Lead for Case & Care Teams

Healthfirst; New Jersey; On-site; USD 103,000 - 149,000; Full time

Benefits offered by this job

Health benefits

Retirement plan

Life Insurance

Incentive programs

Job summary

Healthfirst in the Greater New York City area seeks a Manager of Utilization Management to oversee Case Management teams and ensure high-quality, cost-effective allocation of services and resources. You will lead clinical decisions, coach staff, and coordinate with providers to optimize patient care.

The role requires an Associate’s degree with preferred RN/LPN license, master’s degree, and strong knowledge of CMS/DOH regulations. Excellent communication and leadership skills are essential.

Qualifications

• Associate’s degree required.
• Prefers RN/LPN license and master’s degree.
• Experience in managed care/case management and discharge planning.
• CMS/DOH/NY DOH or related regulatory knowledge preferred.

Responsibilities

• Oversees utilization management functions including pre-certification, concurrent review, and referrals.
• Develops goals, provides coaching, and conducts performance reviews.
• Collaborates with medical staff to obtain information for UM decisions.
• Develops analytical reports to monitor efficiency.
• Documents UM activities and rationale in EMR systems.
• Serves as clinical resource to care team to optimize patient care and cost management.
• Performs additional duties as assigned.

Skills

Strong communication

Time management

Critical thinking

Problem solving

Staff supervision

Coaching

Managed care experience

Discharge planning

Analytics reporting

Regulatory knowledge

PHI systems familiarity

Leadership

Education

Associate’s degree

Tools

Microsoft Word

Excel

Outlook

PowerPoint

Access

Visio

Project

Job description

Healthfirst in the Greater New York City area seeks a Manager of Utilization Management to oversee Case Management teams and ensure high-quality, cost-effective allocation of services and resources. You will lead clinical decisions, coach staff, and coordinate with providers to optimize patient care.

The role requires an Associate’s degree with preferred RN/LPN license, master’s degree, and strong knowledge of CMS/DOH regulations. Excellent communication and leadership skills are essential.