Utilization Manager

Acacia Network; New York (NY); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical coverage

Dental and vision coverage

Paid time off

Job summary

Acacia Network is seeking a Utilization Manager to oversee communications with external case managers and MCOs, ensuring data collection, interpretation, and certification/recertification from pre-admission through discharge. The role involves clinical discussion, referral of services to Medical Director when guidelines aren’t met, and review of residential services requiring MCO approval.

The candidate should have strong analytical skills, effective communication with leadership, and experience

Qualifications

• Minimum 2 years of case management and/or utilization review experience.
• Strong problem-solving and advanced analytical skills.
• Excellent oral, written, organizational and interpersonal communication skills.
• Ability to communicate effectively with senior leadership and MCOs.
• Demonstrated ability to collaborate with peers and senior leadership on projects.

Responsibilities

• Obtain pre-authorization/certification from MCOs and communicate changes to Finance.
• Perform ongoing medical necessity reviews and update MCO status as required.
• Serve as liaison between residential program and MCO to facilitate reimbursement.
• Refer denials and non-covered services for appeal and next steps.
• Review medical records for managed care patients within the requested timeframes.
• Collaborate with clinicians to identify discharge needs and coordinate with Social Services.
• Coordinate post-discharge follow-up with patients and community providers.
• Maintain confidentiality and compliance with state/federal regulations.

Job description

Are you ready to give back to the community while pursuing your passion? For over 50 years, Acacia Network and its affiliates have been committed to improving the quality-of-life and wellbeing of underserved communities in New York City and beyond. We are one of the leading human services organizations in New York City and the largest Hispanic-led nonprofit in the State, serving over 150,000 individuals every year. Our programs serve individuals at every age and developmental level, from the very young through our daycare programs to mature adults through our older adults centers. Our extensive array of community-based services are fully integrated, bilingual and culturally competent.

POSITION OVERVIEW

The Utilization Manager is responsible for the day-to-day functions of collaborative communication with external case managers at referring provider facilities and/or managed care organizations (MCO) for data collection, interpretation, and certification/recertification from third party payers at pre-admission through discharge, ongoing medical necessity reviews and interdisciplinary team support with respect to MCO requisites. In addition, this position is responsible for having a thorough understanding of patient treatment plans through participative discussions with the care plan (interdisciplinary) team, identifying and referring requests for services to the Medical Director when guidelines are not met and reviewing residential services requiring MCO approval.

KEY ESSENTIAL FUNCTIONS

• 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.
• Collaborate with clinicians to identify discharge needs and coordinates with Social Services in the creation and implementation of a discharge/transfer plan.
• Coordinates post-discharge follow-up care with selected patients and community providers.
• Maintains strong leadership skills to perform the multiple functions and a wide variety of tasks requiring independent judgment, ingenuity, and initiative.
• Interacts with executives, directors, key members of the residential team, physicians, and their staff, third party payers, state and federal agencies, auditors, and vendors.
• Maintains a high degree of computer proficiency with MS Word and MS Excel which is critical for the analysis conducted using this technology.
• Maintains all information in a manner such as to assure strict confidentiality and compliance with HIPPAA.
• Maintains full knowledge and understanding of state and federal regulations as they pertain to resident assessment requirements.
• Performs all other tasks including miscellaneous special projects as directed.

REQUIREMENTS

• 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.

WHY JOIN US?

Acacia Network providesa comprehensive and competitive benefits package to our employees. In addition to a competitive salary, our benefits include medical, dental, and vision coverage. We also offer generous paid time off, including vacation days and paid holidays, to support a healthy work-life balance. We prioritize the well-being of our employees both professionally and personally.

As an Equal Opportunity Employer, we encourage individuals from all backgrounds to apply.