Case Manager – Utilization Management

in New York City
, NY
Reference: 19-03965


The Case Manager coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned. The Case Manager is also responsible for efficient utilization of health services and optimal health outcomes for members, as well as meeting designated quality metrics.


  • Provide case management services for assigned member caseloads
  • Perform risk-identification, pre-admission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments
  • Preform service utilizations based on clinical documentation, regulatory, and InterQual/MCG criteria
  • Identify medical, psychological, and social issues that need intervention
  • Partner with medical providers to coordinate treatments, collateral services, and service authorizations
  • Negotiate rates with non-partner providers, where applicable
  • Ensure appropriate access and utilization of a full continuum of network and community resources to support health and recovery
  • Document all determinations, notifications, interventions, and telephone encounters in accordance with established documentation standards and regulatory guidelines
  • Report and escalate questionable healthcare services
  • Meet performance metric requirements as part of annual performance appraisals
  • Monitor assigned case load to meet performance metric requirements
  • Assist in identifying opportunities for and facilitating alternative care options based on member needs and assessments

Minimum Qualifications:

  • RN, LPN, LMSW, LMHC, LMFT and/or LCSW license

Preferred Qualifications:

  • Master’s degree in a related discipline
  • Experience in managed care, case management, identifying alternative care options, and discharge planning
  • Certified Case Manager
  • Interqual and/or Milliman knowledge
  • Knowledge of Centers for Medicare & Medicaid Services (CMS) or New York State Department of Health (NYSDOH) regulations governing medical management in managed care
  • Relevant clinical work experience
  • Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills
  • Demonstrated critical thinking and assessment skills to ensure member care plans are followed
  • Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
  • Demonstrated professional writing, electronic documentation, and assessment skills