• Healthfirst
  • $83,450.00 -117,470.00/year*
  • New York, NY
  • Healthcare - Nursing
  • Full-Time
  • 21 Warren St

The Case Manager, Utilization Management HARP 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.

* Provides case management services for assigned member caseloads which includes:

o 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

o Assessment - identifying medical, psychological, and social issues that need intervention.

o 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

o 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:

Registered Nurse (RN) in New York State


LCSW, LMSW (any state)

Preferred Qualifications:

* Experience in HARP, 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.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status 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 ...@Healthfirst.org or calling 212-###-#### . 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

Associated topics: care, domiciliary, infusion, intensive care unit, mhb, nurse rn, recovery, staff nurse, surgical, transitional

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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