Case Manager – Utilization Management II

This is a fully remote position, open to applicants in Connecticut, +13 more states.

📋 Description

• Oversee care plans for designated members.

• Execute pre-certification, concurrent reviews, discharge planning, and case management.

• Carry out risk identification, preadmission, concurrent, and retrospective assessments for treatment suitability and medical necessity utilizing clinical documentation, regulatory guidelines, and InterQual/MCG standards.

• Recognize medical, psychological, and social challenges that require intervention.

• Collaborate with primary care physicians and other healthcare providers to coordinate treatments, supplementary services, and service authorizations.

• Negotiate pricing with non-partner providers as necessary.

• Ensure access to and effective use of network and community resources.

• Accurately document decisions, notifications, interventions, and phone interactions in accordance with standards and regulations.

• Advocate for, inform, and educate beneficiaries about services, self-management strategies, and health benefits.

• Create and implement care plans that align with physician treatment strategies.

• Report and escalate any questionable healthcare services.

• Monitor caseloads and achieve performance targets.

• Act as a clinical resource for the multidisciplinary care team to enhance member care quality and manage healthcare costs.

• Identify and facilitate alternative care options.

• Occasionally work overtime as required.

• Perform additional assigned responsibilities.

⛳️ Requirements

• RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, and/or ST licensure for Medical Case Management.

• NYS RN or Licensed Social Worker (LCSW/LMSW from any state) for Episodic Utilization/Case Management.

• RN, LPN, LMSW, LMHC, LMFT, or LCSW for Behavioral Health Case Management.

• Minimum of 3 years of experience in a mental/behavioral health or addictions environment.

• Credentialed Alcohol and Substance Abuse Counselor for CASAC roles only.

• Registered Nurse (RN) is preferred.

• Master’s degree in a related field is preferred.

• Experience in managed care, case management, identifying alternative care options, and discharge planning is preferred.

• Certified Case Manager is preferred.

• Familiarity with InterQual and/or Milliman is preferred.

• Understanding of CMS or NYSDOH regulations pertaining to medical management in managed care is preferred.

• Relevant clinical experience is preferred.

• Proficient in Outlook, with basic skills in Word, Excel, PowerPoint, and Adobe Acrobat is preferred.

• Strong critical thinking and assessment abilities.

• Capability to handle large caseloads and perform effectively in a fast-paced environment.

• Excellent professional writing, electronic documentation, and assessment skills.

🏝️ Benefits

• Comprehensive medical, dental, and vision coverage.

• Incentive and recognition programs.

• Life insurance benefits.

• 401(k) contributions.

• Competitive salary and benefits package.