Clinical Utilization Review Manager

Position Summary: The Manager of Utilization Management provides daily oversight for Case Management teams (which includes RN’s, Social Workers, and Coordinators). The Manager of Utilization Management is responsible for ensuring high quality, cost-effective, and appropriate allocation of member services, treatments, and resources. The Manager of Utilization Management serves as a resource to Healthfirst’s care management team, members, and outside medical providers.

- Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, referrals, and other plan services.
- Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions
- Collaborates with medical staff and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems
- Develops and analyzes operational and analytical reports to monitor and track operational efficiency
- Properly documents utilization management activities and rationale for all decisions in electronic medical records systems
- Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management

Minimum Qualifications:

• Associate’s degree

• RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license

• Work experience demonstrating verbal and written communication skills

• Experience working independently in a fast-paced environment that requires problem solving skills and handling multiple priorities simultaneously

• Experience with Microsoft Office Suite applications including Excel, Word, Power Point and Outlook

Preferred Qualifications:

• BSN
• 5+ years of progressive clinical experience in managed care, LTSS, home health, or community-based care,
• 3+ years demonstrated leadership experience.
• Strong expertise in New York State Medicaid LTSS and utilization management, with advanced ability to interpret UAS-NY/Community Health Assessment (CHA) findings and translate NYS medical-necessity criteria into consistent, clinically sound, and compliant LTSS determinations.
• Proven experience leading clinical teams, providing oversight of complex and high-risk cases, and driving consistency and quality in utilization decisions.
• Demonstrated ability to monitor clinical and operational performance, identify trends and opportunities for improvement, strengthen workflows and decision-support practices, and ensure regulatory and audit readiness.
• Strong collaboration skills with Medical Directors, Care Management, Appeals, Compliance, Operations, and other key stakeholders. CCM, ACM, or comparable certification preferred.
• Additional duties as assigned

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC 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. HF Management Services, LLCshallnotdiscriminateagainstanydisabledemployeeorapplicantinregard to any position for which the employee or applicant is otherwise qualified.

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 HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.

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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.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $116,800 - $168,810

• All Other Locations (within approved locations): $99,700 - $148,325

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.