Case Manager - Utilization Management II

The Case Manager, Utilization Management coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned. The Case Manager, Utilization Management is also responsible for efficient utilization of health services and optimal health outcomes for members, as well as meeting designated quality metrics.

• Provides case management services for assigned member caseloads which includes:
  • Pre-certification – performing risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments and service utilizations based on clinical documentation, regulatory, and Inter Qual/MCG criteria
  • Assessment - identifying medical, psychological, and social issues that need intervention.
  • Coordination - partnering with PCP and other medical providers to coordinate treatments, collateral services, and service authorizations. Negotiates rates with non-partner providers, where applicable. Ensures appropriate access and utilization of a full continuum of network and community resources to support health and recovery
  • Documenting - documenting all determinations, notifications, interventions, and telephone encounters in accordance with established documentation standards and regulatory guidelines.
  • Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits.
  • Develops and executes on care plans that align with the physician’s treatment plans and recommends interventions that align with proposed goals as needed
  • Reports and escalates questionable healthcare services
  • Meets performance metric requirements as part of annual performance appraisals
  • Monitors assigned case load to meet performance metric requirements
  • Functions as a clinical resource for the multi-disciplinary care team in order to maximize HF member care quality while achieving effective medical cost management
  • Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments
  • Occasional overtime as necessary
  • Additional duties as assigned

• For Medical Case Management:
  • RN, LPN, LMSW, LMHC,LMFT, LCSW, PT, OT, and/or ST license
  • For Episodic Utilization/Case Management: NYS RN or Licensed Social Worker (LCSW/LMSW any state)
• For Behavioral Health Case Management:
  • RN, LPN, LMSW, LMHC,LMFT, LCSW
  • 3 years of work experience in a mental/behavioral health or addictions setting
  • For CASAC positions only:
    Credentialed Alcohol and Substance Abuse Counselor

• Registered Nurse (RN)
• Master’s degree in a related discipline
• Experience in managed care, case management, identifying alternative care options, and discharge planning
• Certified Case Manager
• Inter Qual and/or Milliman knowledge
• Knowledge of Centers for Medicare & Medicaid Services (CMS) or New York State Department of Health (NYSDOH) regulations governing medical management in managed care
• Relevant clinical work experience
• Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills.
• Demonstrated critical thinking and assessment skills to ensure member care plans are followed.
• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
• Demonstrated professional writing, electronic documentation, and assessment skills.

• Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360
• All Other Locations (within approved locations): $73,400 - $108,160

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to…