Healthfirst Case Manager - Utilization Management (High Acuity Team) in Home Office, New York


The High Acuity Team Care Manager in UM conducts pre-certification of selected services in accordance with departmental, Regulatory, Medicare, Medicaid, MLTC guidelines, and Healthfirst policies and procedures. The individual is responsible for efficient review of the members’ utilization of health services and optimal health outcomes as well as meeting designated metrics.

  • Collaborate and communicate effectively with executives and senior leadership.

  • Work with families and facilities to facilitate appropriate member discharge planning.

  • Work closely with Regulatory and Legal departments on cases involving high risk members and medically complex situations.

  • Collaborate with Medical Director Lead and other clinical departments regarding high acuity cases developing safe Plan of Care in line with departmental, regulatory, Medicare, Medicaid, MLTC guidelines, and Healthfirst policies and procedures.

  • Work with Clinical Manager to develop and streamline workflows and processes for current case criteria as well as future case criteria.

  • Evaluates and authorizes request for personal care services, specialty care, home care, Durable Medical Equipment (DME), outpatient rehab and transportation services from network and out-of-network providers in accordance with departmental guidelines.

  • Collaborates directly with the medical team related to member’s plan of care. Utilizes and evaluates available clinical data, including completed assessments, Aide Task Service Plan (ATSP), physical therapy notes, and other data as applicable to make an appropriate recommendation for quality services.

  • Ensures that services are rendered cost effectively by identifying opportunities for and facilitates member redirection to participating providers instead of out of network usage

  • Participates as an integral member of the Utilization Management team and contributes to its overall effectiveness which includes utilization and case management and assures effective use of medical resources.

  • Documents all interventions and telephone encounters with providers, members and vendors in the appropriate Healthfirst Medical information System (MIS) and in the member's electronic medical record in accordance with established documentation standards to insure integrity of services to members.

  • Identifies members who could benefit from case management services and facilitates referrals and works with assigned care manager to assure coordination of care and services and participates on the Interdisciplinary Care Team (ICT) as necessary.

  • Attend telephonic department meetings.

  • Attends in office training as applicable.

  • Additional duties as assigned

Minimum Qualifications:

  • Registered Nurse

Preferred Qualifications:

  • Registered Nurse (RN) with Bachelor’s Degree.

  • U.S. based work experience as a licensed RN in one or more of the following areas: o Home care o Discharge planning o Care/case management o Utilization management

  • Experience using Microsoft products and proficiency in navigating the Internet and multi-tasking with multiple electronic documentation systems simultaneously (toggling).

  • Aptitude for using a fast-paced proactive vs. reactive approach maneuvering multiple tasks simultaneously including seamlessly changing priorities and achieving goals.

  • An independent thinker with a history of using creative techniques to conduct research, audit information and identify solutions.

  • Ability to think critically and use problem solving skills to assure the member's plan of care is addressed and followed.

  • Previous Care Management and/or Utilization Management experience in an insurance company setting preferred

  • Understanding of how healthcare services impact costs and the ability to identify services that will result in the best quality outcomes of their members.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

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

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