Case Manager – Utilization Management II
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Healthfirst case manager coordinating utilization reviews, care plans, and medical services. Supporting member outcomes while managing healthcare quality and costs.
Responsibilities:
- Coordinate care plans for assigned members
- Conduct pre-certification, concurrent review, discharge planning, and case management
- Perform risk identification, preadmission, concurrent, and retrospective reviews for treatment appropriateness and medical necessity using clinical documentation, regulatory, and InterQual/MCG criteria
- Identify medical, psychological, and social issues requiring intervention
- Partner with PCPs and other medical providers to coordinate treatments, collateral services, and service authorizations
- Negotiate rates with non-partner providers where applicable
- Ensure access to and utilization of network and community resources
- Document determinations, notifications, interventions, and telephone encounters according to standards and regulations
- Advocate, inform, and educate beneficiaries on services, self-management techniques, and health benefits
- Develop and execute care plans aligned with physician treatment plans
- Report and escalate questionable healthcare services
- Monitor caseloads and meet performance metrics
- Serve as a clinical resource for the multidisciplinary care team to maximize member care quality and manage medical costs
- Identify and facilitate alternative care options
- Work occasional overtime as necessary
- Perform additional assigned duties
Requirements:
- RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, and/or ST license for Medical Case Management
- NYS RN or Licensed Social Worker (LCSW/LMSW any state) for Episodic Utilization/Case Management
- RN, LPN, LMSW, LMHC, LMFT, or LCSW for Behavioral Health Case Management
- 3 years of work experience in a mental/behavioral health or addictions setting
- Credentialed Alcohol and Substance Abuse Counselor for CASAC positions only
- Registered Nurse (RN) preferred
- Master’s degree in a related discipline preferred
- Experience in managed care, case management, identifying alternative care options, and discharge planning preferred
- Certified Case Manager preferred
- InterQual and/or Milliman knowledge preferred
- Knowledge of CMS or NYSDOH regulations governing medical management in managed care preferred
- Relevant clinical work experience preferred
- Intermediate Outlook, Basic Word, Excel, PowerPoint, and Adobe Acrobat skills preferred
- Demonstrated critical thinking and assessment skills
- Ability to manage large caseloads and work effectively in a fast-paced environment
- Professional writing, electronic documentation, and assessment skills
Benefits:
- Medical, dental, and vision coverage
- Incentive and recognition programs
- Life insurance
- 401k contributions
- Competitive compensation and benefits package
Similar Jobs
Branch Accounts Manager
Branch Accounts Manager growing Loomis’s banking, ATM, and retail account portfolios. Managing client relationships, proposals, retention, and territory-based growth.
District Manager
District Manager overseeing pharmaceutical representatives, hospital access, performance development, and market activities. Managing VIP engagement, training, reporting, and regional sales execution across China.
Manager, Membership Acquisition
Membership Acquisition Manager growing NeuGroup’s finance and treasury professional network. Prospecting member companies, managing leads, and closing memberships for NeuGroup.
Regional Field Service Manager
Regional Field Service Manager overseeing dental equipment installation, repair, and technicians. Supporting Benco Dental, a full-service U.S. dental distributor, across the Richmond region.
Case Manager
Remote Registered Nurse case manager coordinating disease management, assessments, and care plans for Wholecare Medicaid members. Supporting self-management through telephonic outreach, education, and provider coordination.
Software Publisher Services – Manager
Software Publisher Services Manager delivering contract, license, and royalty compliance audits for Connor. Managing global client projects, data analytics, reporting, and audit teams.
Senior Manager, Organizational Learning & Talent Enablement
Senior manager overseeing learning operations, compliance training, performance management, and talent enablement at global CRO Worldwide Clinical Trials. Leading teams, governance, and enterprise stakeholder partnerships.
Regional Facilities Manager
Regional Facilities Manager leading healthcare facilities teams, client relationships, vendors, budgets, and service delivery. Supporting JLL’s global real estate and investment management services.
Manager, Specialized Care
HR Business Partner supporting Flowserve’s people strategy, employee relations, talent programs, and hiring operations in Mexico. Advising leaders across a business unit to drive culture and results.
Senior Engagement Delivery Manager
Salesforce Engagement Delivery Senior Manager leading complex customer engagements and strategic technology programs. Driving governance, financial performance, risk management, satisfaction, and executive alignment.
Senior Manager, Medical Staff Services
Senior Manager directing Medical Staff Services for Providence’s Kadlec healthcare center in Washington. Overseeing operations, personnel, budgeting, and medical staff compliance.
HMDA/Fair Lending Manager
HMDA/Fair Lending Manager overseeing data quality, reporting, and second-line compliance for Upstart’s AI lending marketplace. Supporting fair lending analysis and responsible automation.
Utilization Manager – Behavioral Health
Duke Health utilization manager overseeing behavioral-health medical necessity, authorization, and denial reviews. Supporting patient flow, discharge planning, audits, and quality improvement.
Subcontracts Manager
Subcontracts Manager negotiating and administering vendor agreements for Magellan Health. Managing compliance, risk, approvals and subcontract performance across government and commercial programs.
Service Delivery Manager
Service Delivery Manager leading customer success, service governance, escalations, and billing for Logicalis managed services clients. Driving operational performance, continuous improvement, and long-term customer value.
Service Delivery Manager
Service Delivery Manager leading customer success, governance, billing, and service improvement for Logicalis managed-services clients. Coordinating cross-functional delivery and executive relationships.
Business Line Manager – Ground Support Division
Business Line Manager leading Sandvik Mining's Ground Support business across Northern Europe. Driving growth, profitability, customer success and technical-commercial excellence.
District Manager
District Manager overseeing pharmaceutical sales representatives, hospital access, training, and regional market performance. Managing VIP engagement, market activities, reporting, and daily field visits in China.
Senior Philanthropy Manager
Senior philanthropy manager cultivating major-donor relationships for Compassion UK & Ireland. Securing transformational gifts that release children from poverty in Jesus’ name.
Claims Manager – Commercial Auto Excess Casualty
Claims Manager leading commercial auto excess casualty claims at Reserv, an AI-driven insurtech. Overseeing specialists, complex claims, automation, compliance, and client reporting.