Clinical Manager of Utilization Management

    • Flexible / Remote

Position Summary:

The Manager of Utilization Management provides daily oversight for Case Management teams (which includes RN's, Social Workers, and Coordinators). The Manager of Utilization Management is responsible for ensuring high quality, cost-effective, and appropriate allocation of member services, treatments, and resources. The Manager of Utilization Management serves as a resource to Healthfirst's care management team, members, and outside medical providers.

- Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, referrals, and other plan services.
- Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions
- Collaborates with medical staff and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems
- Develops and analyzes operational and analytical reports to monitor and track operational efficiency
- Properly documents utilization management activities and rationale for all decisions in electronic medical records systems
- Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management
- Additional duties as assigned

Minimum Qualifications:

Associate's degree
RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license
Master's degree in a related discipline
Excellent communication, time management, critical thinking, and problem solving skills.
Supervisory, training, or management experience
Experience in managed care, case management, identifying alternative care options, and discharge planning across a variety of treatment settings for high risk, complex populations
Certified Case Manager
Interqual, Milliman, and/or TruCare knowledge
Knowledge of Centers for Medicare & Medicaid Services (CMS), New York State Department of Health (NYSDOH), or MLTCP regulations governing medical management in managed care
Intermediate Microsoft Word, Excel, Outlook, Powerpoint, Access, Adobe, Visio, and Project skills. 
Familiarity with PHI systems
Work experience in managed care or healthcare industry in utilization management including preauthorization of outpatient or inpatient services
Knowledge of utilization management/quality management case philosophies and reporting requirements to NY state and federal agencies.
Ability to allocate, monitor, and control resources while delegating and monitoring workloads
Ability to work in a fast-paced environment while building and enhancing team productivity
Demonstrated professionalism and leadership skills along with the ability to develop, direct, and support staff

Compliance & Regulatory Responsibilities: The Manager is responsible for ensuring regulatory compliance with CMS, DOH, internal, and other relevant rules.

- Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, referrals, and other plan services.
- Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions
- Collaborates with medical staff and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems
- Develops and analyzes operational and analytical reports to monitor and track operational efficiency
- Properly documents utilization management activities and rationale for all decisions in electronic medical records systems
- Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management
- Additional duties as assigned

Minimum Qualifications:

  • Associate's degree
  • RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license
  • Master's degree in a related discipline
  • Excellent communication, time management, critical thinking, and problem solving skills.
  • Supervisory, training, or management experience
  • Experience in managed care, case management, identifying alternative care options, and discharge planning across a variety of treatment settings for high risk, complex populations
  • Certified Case Manager
  • Interqual, Milliman, and/or TruCare knowledge
  • Knowledge of Centers for Medicare & Medicaid Services (CMS), New York State Department of Health (NYSDOH), or MLTCP regulations governing medical management in managed care
  • Intermediate Microsoft Word, Excel, Outlook, Powerpoint, Access, Adobe, Visio, and Project skills. 
  • Familiarity with PHI systems
  • Work experience in managed care or healthcare industry in utilization management including preauthorization of outpatient or inpatient services
  • Knowledge of utilization management/quality management case philosophies and reporting requirements to NY state and federal agencies.
  • Ability to allocate, monitor, and control resources while delegating and monitoring workloads
  • Ability to work in a fast-paced environment while building and enhancing team productivity
  • Demonstrated professionalism and leadership skills along with the ability to develop, direct, and support staff


Compliance & Regulatory Responsibilities: The Manager is responsible for ensuring regulatory compliance with CMS, DOH, internal, and other relevant rules.

Minimum Qualifications:

  • Associate's degree


Preferred Qualifications:

  • RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license
  • Master's degree in a related discipline
  • Excellent communication, time management, critical thinking, and problem solving skills.
  • Supervisory, training, or management experience
  • Experience in managed care, case management, identifying alternative care options, and discharge planning across a variety of treatment settings for high risk, complex populations
  • Certified Case Manager
  • Interqual, Milliman, and/or TruCare knowledge
  • Knowledge of Centers for Medicare & Medicaid Services (CMS), New York State Department of Health (NYSDOH), or MLTCP regulations governing medical management in managed care
  • Intermediate Microsoft Word, Excel, Outlook, Powerpoint, Access, Adobe, Visio, and Project skills. 
  • Familiarity with PHI systems
  • Work experience in managed care or healthcare industry in utilization management including preauthorization of outpatient or inpatient services
  • Knowledge of utilization management/quality management case philosophies and reporting requirements to NY state and federal agencies.
  • Ability to allocate, monitor, and control resources while delegating and monitoring workloads
  • Ability to work in a fast-paced environment while building and enhancing team productivity
  • Demonstrated professionalism and leadership skills along with the ability to develop, direct, and support staff


Compliance & Regulatory Responsibilities: The Manager is responsible for ensuring regulatory compliance with CMS, DOH, internal, and other relevant rules.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement


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