Healthfirst is hiring a Case Manager - Utilization Management II to coordinate care and ensure the efficient, medically necessary use of health services for our members. In this 100% remote role, you will be responsible for managing a caseload through pre-certification, concurrent review, and discharge planning to achieve optimal health outcomes and meet quality metrics.

What You'll Do

Provide case management services for assigned member caseloads.
Perform pre-certification, concurrent, and retrospective reviews using clinical documentation and InterQual/MCG criteria.
Identify medical, psychological, and social issues requiring intervention.
Partner with PCPs and medical providers to coordinate treatments and service authorizations.
Negotiate rates with non-partner providers where applicable.
Ensure appropriate access and utilization of network and community resources.
Document all determinations, notifications, and interventions per regulatory standards.
Report and escalate questionable healthcare services.
Meet established performance metric requirements for your caseload.
Function as a clinical resource for the multi-disciplinary care team.
Assist in identifying and facilitating alternative care options based on member needs.
Work occasional overtime as necessary.

What We're Looking For

Current RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, and/or ST license.
For CASAC positions only: Credentialed Alcohol and Substance Abuse Counselor certification.

Nice to Have

Master’s degree in a related discipline.
Experience in managed care, case management, identifying alternative care options, and discharge planning.
Certified Case Manager credential.
Knowledge of Interqual and/or Milliman guidelines.
Knowledge of CMS or NYSDOH regulations governing medical management in managed care.
Relevant clinical work experience.
Intermediate Outlook, Basic Word, Excel, PowerPoint, and Adobe Acrobat skills.
Demonstrated critical thinking and assessment skills.
Demonstrated ability to manage large caseloads in a fast-paced environment.

Benefits & Compensation

Medical, dental, and vision coverage.
Incentive and recognition programs.
Life insurance.
401k contributions.
Compensation: Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480 | All Other Locations (within approved locations): $71,594 - $106,080

Work Mode

This is a 100% remote position. Approved locations include the Greater New York City Area (for NY, NJ, CT residents) and all other pre-approved locations.

Healthfirst complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis.