Manager, Clinical Utilization Management

HealthFirst•Remote - NY, CT

3d•$88,700 - $149,430

About The Position

The Manager of Utilization Management provides daily oversight for Case Management teams, including RNs, Social Workers, and Coordinators. The role ensures high-quality, cost-effective, and appropriate allocation of member services, treatments, and resources, and serves as a resource to Healthfirst’s care management team, members, and outside medical providers. The Manager oversees utilization management functions, including timely authorizations for pre-certification, concurrent review, referrals, and other plan services. The role also supports staff performance and development, collaborates with medical staff on complex clinical matters, monitors operational efficiency, documents utilization management decisions, and helps the multidisciplinary care team maximize patient care quality while managing medical costs. The Manager is responsible for ensuring regulatory compliance with CMS, DOH, internal, and other relevant rules.

Requirements

Associate’s degree.
Excellent communication, time management, critical thinking, and problem-solving skills.
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, including the ability to develop, direct, and support staff.

Nice To Haves

RN or LPN clinical license.
Master’s degree in a related discipline.
Supervisory, training, or management experience.
Experience in managed care, case management, identifying alternative care options, and discharge planning across varied treatment settings for high-risk, complex populations.
Certified Case Manager credential.
Knowledge of InterQual, Milliman, and/or TruCare.
Knowledge of CMS, New York State Department of Health (NYSDOH), or MLTCP regulations governing medical management in managed care.
Intermediate skills in Microsoft Word, Excel, Outlook, PowerPoint, Access, Adobe, Visio, and Project.
Familiarity with PHI systems.
Work experience in managed care or the healthcare industry in utilization management, including preauthorization of outpatient or inpatient services.
Knowledge of utilization management and quality management case philosophies and reporting requirements to New York State and federal agencies.

Responsibilities

Oversee utilization management functions, including timely authorizations related to pre-certification, concurrent review, referrals, and other plan services.
Develop and monitor staff goals; provide ongoing feedback and coaching; conduct annual performance reviews; lead by example; and foster open communication, teamwork, ownership, and empowerment to make informed decisions.
Collaborate with medical staff and review medical charts to obtain additional information needed for appropriate utilization management and to solve complex clinical problems.
Develop and analyze operational and analytical reports to monitor and track operational efficiency.
Document utilization management activities and the rationale for all decisions in electronic medical records systems.
Serve as an ongoing clinical resource for the multidisciplinary care team to maximize patient care quality while achieving effective medical cost management.
Ensure regulatory compliance with CMS, DOH, internal, and other relevant rules.
Perform additional duties as assigned.