Behavioral Health Utilization Management Case Manager

Health First • New York, NY

394d

About The Position

The position involves providing case management services for assigned member caseloads, focusing on evaluating the appropriateness and medical necessity of treatments and service utilizations. The role requires coordination with healthcare providers, documentation of services, and monitoring of performance metrics to ensure quality care and effective medical cost management.

Requirements

• RN, LPN, LMSW, LMHC, LMFT, LCSW.

Nice To Haves

• Masters degree in a related discipline.
• Experience in managed care, case management, identifying alternative care options, and discharge planning.
• Certified Case Manager.
• Milliman knowledge.
• Knowledge of CMS or 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.
• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment.
• Demonstrated professional writing, electronic documentation, and assessment skills.

Responsibilities

• Provides case management services for assigned member caseloads.
• Conducts pre-certification performing risk-identification, preadmission, concurrent, and retrospective reviews.
• Identifies medical, psychological, and social issues that need intervention.
• Partners with PCP and other medical providers to coordinate treatments and services.
• Negotiates rates with non-partner providers where applicable.
• Documents all determinations, notifications, interventions, and telephone encounters.
• 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.
• Assists in identifying opportunities for and facilitating alternative care options.
• Occasional overtime as necessary.
• Performs additional duties as assigned.

Benefits

• Equal opportunity employer with a commitment to diversity and inclusion.

What This Job Offers

• Job Type: Full-time
• Industry: Ambulatory Health Care Services
• Education Level: Associate degree