Healthfirst Field Case Manager - UM - Behavioral Health in New York, New York
The Case Manager - Field, Utilization Management coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned. This position has face-to-face member contact depending on the hospital's limitations and stipulations and therefore, travel to hospitals/free standing facilities is required. This position is expected to collaborate with hospital clinicians and a Care Management team (which may include RN’s, Social Workers, and Coordinators) to evaluate and treat members and provides education and consultation to members, family/caregivers, and other people responsible for the member’s shared care. The Case Manager – Field is also responsible for efficient utilization of health services and optimal health outcomes for members, as well as meeting designated quality metrics.
Provides case management services for assigned member caseloads including:
Providing overall case management services for assigned member caseloads
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 MCG criteria and Locadtr
Ensuring appropriate access and utilization of a full continuum of network and community resources to support health and recovery
Additional duties as assigned.
RN, LMSW, LMHC, LMFT and/or LCSW license
Travel to healthcare facilities as assigned
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
Demonstrated professional writing, electronic documentation, and assessment skills.
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