Case Manager – Utilization Management II

Healthfirst

. Coordinate care plans for assigned members .

Posted 9/23/2026full-timeRemote • United StatesMid-LevelSenior💰 $73,400 - $108,160 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Medical Case Management, including care plan coordination, risk identification, and compliance with regulatory standards. Proficient in collaborating with healthcare providers and managing large caseloads while ensuring quality member care and effective documentation.

Highest-signal resume keywords

Medical Case ManagementInterQual KnowledgeBehavioral Health Case ManagementCritical Thinking SkillsCertified Case Manager

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Care Plan CoordinationRisk IdentificationDischarge PlanningClinical DocumentationPerformance Metrics MonitoringElectronic DocumentationAssessment SkillsManaged Care ExperienceAlternative Care Options IdentificationNegotiation Skills

Soft Skills

AdvocacyCommunicationCollaborationProblem-SolvingTime Management

Tools & Technologies

OutlookWordExcelPowerPointAdobe Acrobat

Certifications & Qualifications

RN LicenseLCSW LicenseLMSW LicenseCredentialed Alcohol and Substance Abuse CounselorCertified Case Manager

Industry Keywords

Managed CareCMS RegulationsNYSDOH RegulationsClinical ResourceBehavioral Health

About the role

Key responsibilities & impact

Coordinate care plans for assigned members
Conduct pre-certification, concurrent review, discharge planning, and case management
Perform risk identification, preadmission, concurrent, and retrospective reviews for treatment appropriateness and medical necessity using clinical documentation, regulatory, and InterQual/MCG criteria
Identify medical, psychological, and social issues requiring intervention
Partner with PCPs and other medical providers to coordinate treatments, collateral services, and service authorizations
Negotiate rates with non-partner providers where applicable
Ensure access to and utilization of network and community resources
Document determinations, notifications, interventions, and telephone encounters according to standards and regulations
Advocate, inform, and educate beneficiaries on services, self-management techniques, and health benefits
Develop and execute care plans aligned with physician treatment plans
Report and escalate questionable healthcare services
Monitor caseloads and meet performance metrics
Serve as a clinical resource for the multidisciplinary care team to maximize member care quality and manage medical costs
Identify and facilitate alternative care options
Work occasional overtime as necessary
Perform additional assigned duties

Requirements

What you’ll need

RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, and/or ST license for Medical Case Management
NYS RN or Licensed Social Worker (LCSW/LMSW any state) for Episodic Utilization/Case Management
RN, LPN, LMSW, LMHC, LMFT, or LCSW for Behavioral Health Case Management
3 years of work experience in a mental/behavioral health or addictions setting
Credentialed Alcohol and Substance Abuse Counselor for CASAC positions only
Registered Nurse (RN) preferred
Master’s degree in a related discipline preferred
Experience in managed care, case management, identifying alternative care options, and discharge planning preferred
Certified Case Manager preferred
InterQual and/or Milliman knowledge preferred
Knowledge of CMS or NYSDOH regulations governing medical management in managed care preferred
Relevant clinical work experience preferred
Intermediate Outlook, Basic Word, Excel, PowerPoint, and Adobe Acrobat skills preferred
Demonstrated critical thinking and assessment skills
Ability to manage large caseloads and work effectively in a fast-paced environment
Professional writing, electronic documentation, and assessment skills

Benefits

Comp & perks

Medical, dental, and vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Competitive compensation and benefits package