UM Case Manager

at Healthfirst in Remote, United States

**This position is 100% Remote

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

Minimum Qualifications:

RN, LPN , LMSW , LMHC , LMFT , LCSW , PT, OT, and/or ST license

For CASAC positions only: Credentialed Alcohol and Substance Abuse Counselor

Preferred Qualifications:

+ Masters 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

+ Demon