UM Case Manager - LPN/RN, New York, NY

Created 10/14/2021
Reference 1121808
Job type Full Time
State NY
City New York
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.

Duties/Responsibilities:
  • 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

Minimum Qualifications:
  • RN, LPN, LMSW, LMHC,LMFTand/or LCSW license

Preferred Qualifications:
  • 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.

Please note: Since we care so greatly about our employees' and members' wellbeing, Healthfirst is moving to a fully vaccinated in-office environment. You must be vaccinated to work in our offices, even if you are partially remote. If you are selected to interview for this role, we will explain our vaccination policy and ensure you are comfortable moving forward with further interviews based on your work location.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.
Employer Healthfirst Inc.

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