Therapy Manager
Brightline
ERP
UM Case Manager
Healthfirst
full-time
Posted on:
Origin: • 🇺🇸 United States • Louisiana, New York
Visit company websiteSalary
💰 $71,594 - $116,480 per year
Job Level
Mid-LevelSenior
About the role
- Coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned
- Responsible for efficient utilization of health services and optimal health outcomes for members
- Provides case management services for assigned member caseloads including pre-certification, risk-identification, preadmission, concurrent and retrospective reviews to evaluate appropriateness and medical necessity
- Assessment: identifying medical, psychological, and social issues that need intervention
- 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
- Documents all determinations, notifications, interventions, and telephone encounters per documentation standards and regulatory guidelines
- Reports and escalates questionable healthcare services
- Meets performance metric requirements and monitors assigned caseload
- Functions as a clinical resource for the multi-disciplinary care team to maximize 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
Requirements
- RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, and/or ST license
- Master’s degree in a related discipline (preferred)
- Experience in managed care, case management, identifying alternative care options, and discharge planning
- Certified Case Manager (preferred)
- Interqual and/or Milliman knowledge (preferred)
- Knowledge of Centers for Medicare & Medicaid Services (CMS) or New York State Department of Health (NYSDOH) regulations governing medical management in managed care (preferred)
- Relevant clinical work experience
- Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills
- Demonstrated critical thinking and assessment skills
- Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
- Demonstrated professional writing, electronic documentation, and assessment skills
