Description and Requirements

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

• 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.