Clinical Utilization Review Manager

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.

• Associate’s degree RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license
• Work experience demonstrating verbal and written communication skills
• Experience working independently in a fast-paced environment that requires problem solving skills and handling multiple priorities simultaneously
• Experience with Microsoft Office Suite applications including Excel, Word, Power Point and Outlook

• BSN 5+ years of progressive clinical experience in managed care, LTSS, home health, or community-based care, 3+ years demonstrated leadership experience.
• Strong expertise in New York State Medicaid LTSS and utilization management, with advanced ability to interpret UAS-NY/Community Health Assessment (CHA) findings and translate NYS medical-necessity criteria into consistent, clinically sound, and compliant LTSS determinations.
• Proven experience leading clinical teams, providing oversight of complex and high-risk cases, and driving consistency and quality in utilization decisions.
• Demonstrated ability to monitor clinical and operational performance, identify trends and opportunities for improvement, strengthen workflows and decision-support practices, and ensure regulatory and audit readiness.
• Strong collaboration skills with Medical Directors, Care Management, Appeals, Compliance, Operations, and other key stakeholders.
• CCM, ACM, or comparable certification preferred.

Additional duties as assigned

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.

HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis.

HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

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