Utilization Management Leader — Case Care Optimization

HealthFirst

Florida

On-site

USD 103,000 - 149,000

Full time

5 days ago

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Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401k contributions

Incentive programs

Life insurance

Job summary

HealthFirst seeks a Manager of Utilization Management to oversee Case Management teams (RNs, social workers, coordinators) and ensure high-quality, cost-conscious member care and appropriate use of services.

You will lead pre-certification, concurrent review, referrals, and related processes; coach staff; document decisions in EMR; and collaborate with clinical colleagues to optimize outcomes and manage costs.

Qualifications

Experience in managed care case management and discharge planning.
Knowledge of CMS/NYSDOH/MLTCP regulations governing medical management.
Ability to analyze charts and information to support utilization decisions.
Proficient with common office software and EMR systems.
Strong leadership, coaching, and performance review skills.

Responsibilities

Oversees utilization management functions including pre-certification and concurrent review.
Provides coaching, conducts performance reviews, and collaborates with medical staff.
Documents utilization activities and rationale in EMR systems.
Acts as clinical resource to maximize patient care quality and cost management.
Exhibits strong communication, time management, and problem solving.