Manager, Clinical Utilization Management

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 - Addition