Employment Type : Full-Time
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.
Provides case management services for assigned member caseloads which includes: Pre-certification –pre-admission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity for Long-Term Acute Care Hospital (LTACH), Acute Rehabilitation (AR), and Skilled Nursing Facility (SNF), service utilizations based on clinical documentation, regulatory, and MCG criteria.
Assessment - identifying medical, psychological, and social issues that need intervention.
Coordination - partnering with providers to coordinate treatments, collateral services, safe transition/discharge plan.
Request single case agreement (SCA) for out-of-network providers, when applicable.
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
Process initial and continued stay denials
Participate in rounds with peer advisor
Follow-up on appeal requests and determinations
Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments
Occasional overtime as necessary
Additional duties as assigned
Provides case management services for assigned member caseloads which includes:
Pre-certification –pre-admission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity for Long-Term Acute Care Hospital (LTACH), Acute Rehabilitation (AR), and Skilled Nursing Facility (SNF), service utilizations based on clinical documentation, regulatory, and MCG criteria.
Assessment - identifying medical, psychological, and social issues that need intervention.
Coordination - partnering with providers to coordinate treatments, collateral services, safe transition/discharge plan.
Request single case agreement (SCA) for out-of-network providers, when applicable.
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
Process initial and continued stay denials
Participate in rounds with peer advisor-Follow-up on appeal requests and determinations
Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments
Occasional overtime as necessary
Additional duties as assigned
Preferred requirement
RN, LPN, LCSW, Social Worker, Physical Therapist
Please note: Since we care so greatly about our employees' and members' wellbeing, Healthfirst is moving to an environment where our employees are fully vaccinated against COVID-19. As a prospective new team member, you must be fully vaccinated with a CDC/FDA approved COVID-19 shot(s) to work in our offices. If you are selected to interview for this role, we will explain our vaccination policy in further detail and ensure you are comfortable moving forward with this company policy.
This position will require the successful candidate to show proof of vaccination against COVID-19. As an equal opportunity employer, the Company will provide reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.
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.