Manager, Clinical Utilization Management

This is a fully remote position, open to applicants in Connecticut, +4 more states.

📋 Description

• Provide daily supervision for Case Management teams, which include RNs, Social Workers, and Coordinators.

• Ensure the delivery of high-quality, cost-effective member services, treatments, and resource allocation.

• Act as a resource for Healthfirst’s care management team, members, and external medical providers.

• Oversee utilization management tasks, including timely authorizations for pre-certification, concurrent review, referrals, and other plan services.

• Develop and track staff objectives; offer feedback and coaching; conduct annual performance evaluations.

• Lead by example, fostering open communication, teamwork, accountability, and empowered decision-making.

• Collaborate with medical personnel and review medical charts to gather information for utilization management and resolve intricate clinical issues.

• Create and assess operational and analytical reports to evaluate operational efficiency.

• Record utilization management activities and the rationale for decisions in electronic medical record systems.

• Serve as a clinical resource for the multidisciplinary care team to enhance patient care quality and manage medical expenses.

• Ensure adherence to CMS, DOH, internal, and other applicable regulations.

• Perform additional responsibilities as assigned.

⛳️ Requirements

• Associate’s degree.

• Strong communication, time management, critical thinking, and problem-solving abilities.

• Experience in supervision, training, or management.

• Background in managed care, case management, identifying alternative care options, and discharge planning for high-risk, complex populations.

• Certified Case Manager.

• Familiarity with InterQual, Milliman, and/or TruCare.

• Understanding of CMS, NYSDOH, or MLTCP regulations related to medical management in managed care.

• Intermediate proficiency in Microsoft Word, Excel, Outlook, PowerPoint, Access, Adobe, Visio, and Project.

• Knowledge of PHI systems.

• Work experience in managed care or the healthcare industry focused on utilization management, including preauthorization of outpatient or inpatient services.

• Awareness of utilization management/quality management case philosophies and reporting obligations to NY state and federal agencies.

• Ability to allocate, monitor, and manage resources while delegating and overseeing workloads.

• Capability to thrive in a fast-paced environment while enhancing team productivity.

• Proven professionalism and leadership skills, with the ability to develop, guide, and support staff.

• RN or LPN clinical license (preferred).

• Master’s degree in a related field (preferred).

🏝️ Benefits

• Medical, dental, and vision coverage.

• Incentive and recognition programs.

• Life insurance.

• 401k contributions.

• Competitive compensation and benefits package.