Clinical Utilization Review Manager

HealthFirst•Hybrid - NY, NY

1d•$99,700 - $168,810•Remote

About The Position

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.

Requirements

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

Nice To Haves

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.

Responsibilities

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