Manager, Clinical Utilization Management
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Posted: 10/20/2026
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Posted: 10/20/2026Manager, Clinical Utilization Management
HealthfirstCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in case management and utilization management, ensuring compliance with CMS and DOH regulations while effectively leading and developing multidisciplinary teams. Proficient in analyzing operational reports and managing resources to enhance patient care quality and operational efficiency.
Highest-signal resume keywords
Certified Case ManagerUtilization ManagementManaged Care ExperienceKnowledge of InterQualSupervisory Experience
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 solve complex clinical problems
- Develop and analyze operational and analytical reports to monitor operational efficiency
- Document utilization management activities and decision rationales in electronic medical record systems
- Function as a clinical resource for the multidisciplinary care team to maximize patient care quality and manage medical costs
- Ensure compliance with CMS, DOH, internal, and other relevant rules
- Perform additional duties as assigned
Requirements
What you’ll need- Associate’s degree
- Excellent communication, time management, critical thinking, and problem solving skills
- Supervisory, training, or management experience
- Experience in managed care, case management, identifying alternative care options, and discharge planning across a variety of treatment settings for high risk, complex populations
- Certified Case Manager
- Knowledge of InterQual, Milliman, and/or TruCare
- Knowledge of CMS, NYSDOH, or MLTCP regulations governing medical management in managed care
- Intermediate skills in Microsoft Word, Excel, Outlook, PowerPoint, Access, Adobe, Visio, and Project
- Familiarity with PHI systems
- Work experience in managed care or healthcare industry in utilization management, including preauthorization of outpatient or inpatient services
- Knowledge of utilization management/quality management case philosophies and reporting requirements to NY state and federal agencies
- Ability to allocate, monitor, and control resources while delegating and monitoring workloads
- Ability to work in a fast-paced environment while building and enhancing team productivity
- Demonstrated professionalism and leadership skills, along with the ability to develop, direct, and support staff
- RN or LPN clinical license (preferred)
- Master’s degree in a related discipline (preferred)
Benefits
Comp & perks- Medical, dental, and vision coverage
- Incentive and recognition programs
- Life insurance
- 401k contributions
- Competitive compensation and benefits package
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ManagementCase ManagementOperational AnalysisResource AllocationPreauthorization ProcessesDischarge PlanningKnowledge of CMS RegulationsKnowledge of MLTCP RegulationsKnowledge of NYSDOH RegulationsClinical Resource Management
Soft Skills
Excellent CommunicationTime ManagementCritical ThinkingProblem SolvingLeadership Skills
Tools & Technologies
Microsoft WordMicrosoft ExcelMicrosoft OutlookMicrosoft PowerPointMicrosoft AccessAdobeVisioMicrosoft ProjectElectronic Medical Record SystemsPHI Systems
Certifications & Qualifications
Certified Case ManagerRN or LPN Clinical License
Industry Keywords
Managed CareHealthcare IndustryUtilization ManagementQuality ManagementComplex PopulationsClinical ProblemsTeam ProductivityPerformance ReviewsCost-Effective ServicesMember Services