Case Manager - UM II -100% Remote

Healthfirst provides health insurance at little to no cost to eligible children, adults, and families in NYC.

Description and Requirements

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.

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/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

Description and Requirements

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.

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/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:

• 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

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• Greater New York City Area (NY, NJ, CT residents): $81,099 – $116,480
• All Other Locations (within approved locations): $71,594 – $106,080

:

• Greater New York City Area (NY, NJ, CT residents): $81,099 – $116,480
• All Other Locations (within approved locations): $71,594 – $106,080

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.

Hiring Range:

• Greater New York City Area (NY, NJ, CT residents): $81,099 – $116,480
• All Other Locations (within approved locations): $71,594 – $106,080

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.

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, LLC shall not discriminate against any disabled employee or applicant in regard 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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Client-provided location(s): Flexible / Remote

Job ID: healthfirst-R020709

Employment Type: OTHER

Posted: 2025-08-06T16:54:29

Perks and Benefits

Health and Wellness

• Health Insurance
• Health Reimbursement Account
• Vision Insurance
• Life Insurance
• Short-Term Disability
• Long-Term Disability
• FSA
• HSA
• Fitness Subsidies
• Pet Insurance
• Birth Parent or Maternity Leave
• Family Support Resources

Work Flexibility

Office Life and Perks

• Commuter Benefits Program
• Casual Dress
• Happy Hours
• Company Outings
• Holiday Events

Vacation and Time Off

• Paid Vacation
• Paid Holidays
• Personal/Sick Days

Financial and Retirement

• 401(K) With Company Matching
• Performance Bonus

Professional Development

• Internship Program
• Tuition Reimbursement
• Promote From Within
• Access to Online Courses
• Lunch and Learns
• Associate or Rotational Training Program
• Learning and Development Stipend

Diversity and Inclusion

• Employee Resource Groups (ERG)
• Woman founded/led
• Diversity, Equity, and Inclusion Program

Company Videos

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