Director Utilization Management Job at Healthfirst (New York)

Director, Utilization Management

The Director of Utilization Management is a transformational clinical operations...

Location

United States , New York

Salary:

127500.00 - 236555.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

Bachelor’s degree in healthcare, business, or a related field from an accredited institution or equivalent work experience
Progressive leadership experience in healthcare management including work experience in a mid-senior management role
Work experience and deep familiarity of health plans such as Medicare, Medicaid and/or Managed Long-Term Care Plan (MLTCP).
Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations
Work experience interpreting and operationalizing regulatory updates and guidance from DOH and CMS.
Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across all levels and functions.
Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment.

Job Responsibility

Provide strategic direction and leadership to UM leaders and teams executing department functions including prior authorizations, concurrent reviews, and service requests
Develop strong operational and leadership capabilities within the organization through performance improvement, career development, and coaching
Develop and implement policies and procedures that align with industry standards, payer guidelines, and regulatory requirements
Deliver on Healthfirst’s Mission by ensuring optimum quality of member care in a cost-effective manner
Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities
Develop and monitor appropriate metrics to maintain and improve department performance
Collect, analyze, and report on utilization trends, patterns, and impacts to identify areas for improvement
Lead initiatives to improve efficiency, cost-effectiveness, and quality in the UM program, sometimes through the implementation of new technology
Serve as the operational subject matter expert on business development efforts related to UM programs, including the launch of new products or regulatory initiatives
Collaborate closely with other Operations leaders including but not limited to Care Management, Clinical Eligibility, Behavioral Health, and Appeals and Grievances teams to align utilization decisions

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

Fulltime

Medical Director, Utilization Management

The Medical Director, Utilization Management provides clinical oversight of auth...

Location

United States , Los Angeles

Salary:

206311.00 - 350729.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Doctor of Medicine (M.D.)
At least 8 years of experience in medical management, managed care and quality management
Experience in Payment Integrity
Experience in maintaining liaison with Federal, State, and local bodies and medical organizations
Experience in performance management and possession of strong analytic ability
Extensive post-medical degree experience in clinical practice
Significant experience in a clinical development, medical affairs, or management role within the biotech, pharmaceutical, or healthcare industry
Proven experience in a physician leadership role, including managing teams
Ability to provide leadership to physicians, nurses, and other health care professionals
Excellent written and verbal communication skills

Job Responsibility

Provides clinical oversight of authorization decision making and processing, pre and post payment claims review activities, payment integrity clinical validation and program integrity functions
Supports the development of and ensures the application of clinical policies are consistent with evidence-based medicine and regulatory requirements
Collaborates with internal teams to support timely consistent and defensible clinical decisions and promotion of appropriate high-value care
Reviews clinical documentation to validate coding accuracy and appropriateness and completion of billed services
Plays a critical role in the mitigation of Fraud, Waste and Abuse (FWA)
Requires proactive analysis of service level utilization data to identify trends, outliers and emerging risk areas and recommend corrective action
Works collaboratively with Health Services departments and key organizational stakeholders
Partners with executive leadership, clinical teams, and external stakeholders to improve outcomes, support regulatory compliance, and advance organizational goals
Provides physician leadership within the Health Services division
Applies clinical expertise and evidence-based criteria to behavioral health and medical/surgical services

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Medical Director of Case Management and Utilization Review

The Medical Director of Case Management and Utilization Review leads the hospita...

Location

United States , Miramar

Salary:

Not provided

Memorial Healthcare System

Expiration Date

Until further notice

Requirements

Medical Doctor (Required)
Medical Doctor License (ME LICENSE) - State of Florida (FL)
Osteopathic Physician License (OS LICENSE) - State of Florida (FL)
Extensive experience in one or more branches of medicine or surgery
at least, five (5) post-training years of medical staff organization/administrative experience in a large acute care hospital
Graduate of a medical school approved by the Council on Medical Education of the American Medical Association
Excellent customer service and interpersonal skills
Able to effectively present information, both formal and informal
Strong written and verbal communications skills with all levels of internal and external customers
Strong analytical skills

Job Responsibility

Supports education and clinical documentation improvement
Leads Complex Care Management
Leads hospital initiatives to reduce complex patient length of stay
Makes decisions on referred individual patient cases regarding pre-admission authorization, medical necessity and services/setting, appropriateness of admission, and continuation stay
Provides peer review services for medical necessity of admission or continued stay
Supports the Senior Medical Director in Medical Staff Education
Assists physicians in improving the quality of their medical necessity documentation
Serves as liaison to insurance companies for prior authorizations and removes barriers to discharge
Supports case management by attending interdisciplinary rounds (IDR) and provides feedback and suggestions to physicians and CMs
Serves as liaison to case management, social workers, nursing staff, individual physicians, and the medical staff

Fulltime

Utilization Review Nurse Health Plans - HP Utilization Management

The Utilization Review Nurse is responsible for determining the clinical appropr...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

Graduate of an accredited school of vocational nursing or equivalent required
Associate’s (ADN) or Bachelor’s (BSN) in Nursing preferred
3 – 5 years of nursing experience preferred
Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required
General computer knowledge and capability to use computers required
LVN license in the state of employment or compact required
RN license in state of employment or compact preferred

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary
Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines
Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination
Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary’s member’s health care for behavioral health care management
Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI)
Protect the confidentiality of data and intellectual property
assures compliance with national health information guidelines
Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities
Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up

Fulltime

Utilization Management Representative

We are looking for a dedicated Utilization Management Representative to join our...

Location

United States , Pearland

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

1–3 years of healthcare experience (utilization management, insurance operations, or medical office preferred)
Experience handling high call volumes in a professional environment
Strong data entry and documentation accuracy
Ability to multitask in a fast-paced setting
Effective communication skills with providers, members, and internal teams
Basic understanding of authorization processes in healthcare or insurance
Experience with EMR/EHR or case management systems
Strong organizational and time management skills

Job Responsibility

Handle inbound calls from providers, members, and facilities regarding authorization requests, status updates, and coverage questions
Review and process authorization requests received via phone, fax, and electronic systems
Create and document authorization cases accurately within utilization management systems or EHR platforms
Route cases requiring medical necessity review to clinical staff (RNs, LVNs, Medical Directors)
Communicate authorization determinations to providers and members in compliance with regulatory requirements
Maintain accurate, timely documentation to support compliance and operational standards
Collaborate with internal teams to ensure efficient case processing and resolution

What we offer

medical
vision
dental
life and disability insurance
401(k) plan

Utilization Management Nurse Consultant

We're building a world of health around every individual — shaping a more connec...

Location

United States , Work At Home, Columbus, Ohio

Salary:

29.10 - 62.32 USD / Hour

CVS Health

Expiration Date

Until further notice

Requirements

Active unrestricted state Registered Nurse licensure in state of residence required
Minimum 5 years of relevant experience in Nursing
At least 1 year of Utilization Management experience in concurrent review or prior authorization
Strong decision-making skills and clinical judgment in independent scenarios
Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms
Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation

Job Responsibility

Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review
Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information
Use established guidelines to authorize services or escalate to Medical Directors as needed
Navigate multiple computer systems efficiently while maintaining accurate documentation
Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills
Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer
Flexibility to provide coverage for other Utilization Management (UM) Nurses across various UM specialty teams as needed, ensuring continuity of care and operational support
Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements

What we offer

Medical, dental, and vision coverage
Paid time off
Retirement savings options
Wellness programs

Fulltime

Utilization Management Nurse Specialist RN II

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of varied RN clinical experience in an acute hospital setting
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting
Registered Nurse (RN) - Active, current and unrestricted California License
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Provision of excellent customer service
Excellent time management and priority-setting skills
Maintains strict member confidentiality and complies with all HIPAA requirements
Strong verbal and written communication skills

Job Responsibility

Facilitates, coordinates, and approves medically necessary referrals that meet established criteria
Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status
Generates approval, modification and denial communications, to include member and provider notification of referral determination
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review
Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers
Acts as a department resource for medical service requests /referral management and processes
Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps
Follows up with caller to provide response or resolution steps

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Facilities Management Director

Working as a Healthcare Facilities Management Director, you lead the overall man...

Location

United States , New York

Salary:

150000.00 - 175000.00 USD / Year

Crothall Healthcare

Expiration Date

Until further notice

Requirements

Bachelor’s Degree in Engineering preferred or a related field
2 years responsibility at a Director Level OR 5 years responsibility at a Director Level in areas of Engineering, Maintenance and Construction in a health care institution with related continuous education courses
The ability to read, comprehend and transmit complicated detailed instructions orally and in writing
Previous Facilities Management experience in an acute care hospital required
Should have proficiency in CMMS Systems, Microsoft Excel, Word, and Outlook
Certified Health Care Facility Manager (CHFM) preferred
Ability to meet established goals and objectives
Possess a strong knowledge and understanding of healthcare building mechanical, structural, and electrical systems
Must have knowledge and expertise in NFPA, TJC, CMS, DNV, EPA, and OSHA codes and regulations and the ability to interpret and implement

Job Responsibility

Reviews and evaluates existing programs, services, policies and procedures
Meets with hospital client and staff as needed to plan, prioritize, coordinate, and/or communicate programs and policies
Supervises flow and quality of work to assure completion of workload and consistency to facility’s standards
Prepares and leads departmental budgets, including utilities energy savings program
Handles and ensures compliance with the Joint Commission, State Health Department, EPA, DEP, ADA, UST, and other regulatory business appointments
Supervises work performance and prepares and/or reviews performance evaluations for assigned personnel
Guides employees of salient features of facility’s personnel and employee relations programs and answers any questions
Plans, coordinates, and supervises construction and development of physical facilities
Reviews, evaluates, and recommends approval of plans for construction
Serves as liaison with contractors, architects, engineers, and material and equipment suppliers

What we offer

Medical
Dental
Vision
Life Insurance/ AD
Disability Insurance
Retirement Plan
Flexible Time Off
Holiday Time Off (varies by site/state)
Associate Shopping Program
Health and Wellness Programs

Fulltime

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Director Utilization Management

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