HealthFirst
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The Case Manager, Utilization Management coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as 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.
This position is 100% Remote
Duties//Responsibilities Minimum Qualifications Preferred Qualifications Hiring Range*:
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 InterQual//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.
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
RN, LPN, LMSW, LMHC,LMFT, LCSW, PT, OT, and//or ST license
For CASAC positions only: Credentialed Alcohol and Substance Abuse Counselor
Master’s degree in a related discipline
Experience in managed care, case management, identifying alternative care options, and discharge planning
Certified Case Manager
Interqual 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.
RN, LPN, LMSW, LMHC,LMFT, LCSW, PT, OT, and//or ST license
For CASAC positions only: Credentialed Alcohol and Substance Abuse Counselor
Master’s degree in a related discipline
Experience in managed care, case management, identifying alternative care options, and discharge planning
Certified Case Manager
Interqual 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): $81,099 - $117,466
All Other Locations (within approved locations): $71,594 - $106,080 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 the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.
Seniority level Not Applicable
Employment type Full-time
Job function Other
Industries Hospitals and Health Care
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The Case Manager, Utilization Management coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as 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.
This position is 100% Remote
Duties//Responsibilities Minimum Qualifications Preferred Qualifications Hiring Range*:
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 InterQual//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.
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
RN, LPN, LMSW, LMHC,LMFT, LCSW, PT, OT, and//or ST license
For CASAC positions only: Credentialed Alcohol and Substance Abuse Counselor
Master’s degree in a related discipline
Experience in managed care, case management, identifying alternative care options, and discharge planning
Certified Case Manager
Interqual 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.
RN, LPN, LMSW, LMHC,LMFT, LCSW, PT, OT, and//or ST license
For CASAC positions only: Credentialed Alcohol and Substance Abuse Counselor
Master’s degree in a related discipline
Experience in managed care, case management, identifying alternative care options, and discharge planning
Certified Case Manager
Interqual 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): $81,099 - $117,466
All Other Locations (within approved locations): $71,594 - $106,080 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 the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.
Seniority level Not Applicable
Employment type Full-time
Job function Other
Industries Hospitals and Health Care
#J-18808-Ljbffr