Case Manager - UM II -100% Remote

HealthFirst; Remote; USD 73,000 - 109,000; Full time

Job summary

A healthcare organization in Connecticut is seeking a Case Manager for Utilization Management to coordinate care plans and enhance health outcomes for members. The role involves conducting pre-certifications, assessing member needs, and collaborating with medical providers. Ideal candidates will have relevant licensure and experience in managed care. Competitive salary range of $73,400 to $108,160 based on location and qualifications.

Benefits

Medical, dental, and vision coverage

Life insurance

401(k) contributions

Qualifications

• Minimum licensure as RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, or ST.
• Experience in managed care and case management is preferred.
• Knowledge of CMS or NYSDOH regulations is a plus.

Responsibilities

• Coordinate care plans and conduct pre-certifications.
• Assess medical and psychological issues for assigned members.
• Document all interactions in accordance with standards.
• Monitor assigned caseload to meet performance metrics.

Skills

Clinical documentation

Risk assessment

Care coordination

Critical thinking

Documenting interventions

Education

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

Master’s degree in a related discipline

Tools

Outlook

Word

Excel

PowerPoint

Adobe Acrobat

Job description

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 and Responsibilities

• 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 caseload to meet performance metric requirements.
• Functions as a clinical resource for the multi‑disciplinary care team 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

• 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.

Hiring Range

• Greater New York City Area (NY, NJ, CT residents): $83,100 – $120,360
• All Other Locations (within approved locations): $73,400 – $108,160. 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 401(k) 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.