Clinical Utilization Review Manager

Healthfirst

. Provide daily oversight for Case Management teams, including RNs, Social Workers, and Coordinators .

Posted 9/24/2026full-timeNew York • United StatesMid-LevelSenior💰 $116,800 - $168,810 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates strong leadership in clinical case management, with expertise in New York State Medicaid LTSS and utilization management. Capable of fostering collaboration among multidisciplinary teams while ensuring high-quality patient care and operational efficiency.

Highest-signal resume keywords

RN, LPN, LMSW, LMHC, LCSW LicenseUtilization ManagementNew York State Medicaid LTSS ExpertiseLeadership ExperienceCCM, ACM Certification

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical Case ManagementOperational Performance MonitoringUAS-NY/Community Health Assessment InterpretationElectronic Medical Records DocumentationProblem-Solving

Soft Skills

Verbal CommunicationWritten CommunicationCollaborationTeamworkCoaching

Tools & Technologies

Microsoft Office SuiteExcelWordPowerPointOutlook

Certifications & Qualifications

CCMACM

Industry Keywords

Managed CareLTSSHome HealthCommunity-Based CareRegulatory Compliance

About the role

Key responsibilities & impact

Provide daily oversight for Case Management teams, including RNs, Social Workers, and Coordinators
Ensure high-quality, cost-effective, and appropriate allocation of member services, treatments, and resources
Serve as a resource to Healthfirst’s care management team, members, and outside medical providers
Oversee utilization management functions, including timely authorizations for pre-certification, concurrent review, referrals, and other plan services
Develop and monitor staff goals; provide feedback and coaching; conduct annual performance reviews
Lead by example and foster open communication, teamwork, ownership, and empowered decision-making
Collaborate with medical staff and review medical charts to obtain information for utilization management and resolve complex clinical problems
Develop and analyze operational and analytical reports to monitor operational efficiency
Document utilization management activities and decision rationales in electronic medical records systems
Function as a clinical resource for the multidisciplinary care team to maximize patient-care quality and manage medical costs
Perform additional duties as assigned

Requirements

What you’ll need

Associate’s degree
RN, LPN, LMSW, LMHC, LCSW, or another relevant clinical license
Work experience demonstrating verbal and written communication skills
Experience working independently in a fast-paced environment requiring problem-solving and handling multiple priorities simultaneously
Experience with Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook
BSN preferred
5+ years of progressive clinical experience in managed care, LTSS, home health, or community-based care preferred
3+ years of demonstrated leadership experience preferred
Strong expertise in New York State Medicaid LTSS and utilization management
Advanced ability to interpret UAS-NY/Community Health Assessment findings and translate NYS medical-necessity criteria into consistent, clinically sound, and compliant LTSS determinations
Proven experience leading clinical teams and overseeing complex and high-risk cases
Demonstrated ability to monitor clinical and operational performance, identify trends and improvement opportunities, strengthen workflows and decision-support practices, and ensure regulatory and audit readiness
Strong collaboration skills with Medical Directors, Care Management, Appeals, Compliance, Operations, and other stakeholders
CCM, ACM, or comparable certification preferred

Benefits

Comp & perks

Medical coverage
Dental coverage
Vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Competitive compensation and benefits package