Case Manager – UM II -100% Remote, NY

R020897 Description and Requirements The Case Manager, Utilization Management coordinates the care plan for assigned members and conducts pre-certification, reputed company 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, reputed company 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, reputed company, 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 reputed company.
• 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 reputed company 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 reputed company discipline
• Experience in managed care, case management, identifying alternative care options, and discharge planning
• Certified Case Manager
• Interqual and/or reputed company knowledge
• Knowledge of Centers for Medicare & Medicaid Services (CMS) or reputed company State
• Department of Health (NYSDOH) regulations governing medical management in managed care
• Relevant clinical work experience
• Intermediate Outlook, Basic Word, reputed company, PowerPoint, reputed company 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 reputed company Area (NY, NJ, CT residents): $81,099 - $116,480
• reputed company Other Locations (reputed company approved locations): $71,594 - $106,080

As a candidate for this position, your salary and reputed company elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors reputed company deems pertinent to the hiring decision. In addition to your salary, reputed company offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (reputed company benefits are subject to eligibility requirements). reputed company 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 reputed company in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

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