Utilization Manager

2 days ago

New York, New York, United States LESC Full time
Job Summary
Description:

Key Responsibilities:

  • Collaborate with the agency's mission to ensure high-quality care delivery to individuals served by assisting CASAC Counselors and supervisory staff with compliance requirements.
  • Develop and maintain effective communication with external case managers, managed care organizations, and third-party payers to ensure data collection, interpretation, and certification/recertification.
  • Participate in interdisciplinary team discussions to understand patient treatment plans, identify service requests, and review residential services requiring MCO approval.
  • Obtain pre-authorization/certification of services from MCOs and communicate end-of-benefit status and reimbursement changes to Finance and other stakeholders.
  • Conduct ongoing medical necessity reviews, evaluating clinical data and submitting documentation to update patient/resident status to MCOs.
  • Act as a liaison between the residential program and MCOs to facilitate the reimbursement process.
  • Refer MCO denials and non-covered medical services to directors for appeal determination and next steps.
  • Perform timely and complete quality and appropriateness reviews of treatment records for residential service sites.
  • Provide supervisory support to CASAC Counselors and Peer Workers as needed, with guidance from Management/Leadership Team.
  • Monitor and evaluate ongoing audits for chart accuracy.
  • Provide direct care services to clients as needed.
  • Assist with maintaining the agency's OASAS reviews and CARF accreditation for the program, including standards review and conformance auditing.
  • Perform other duties as assigned.

Work Schedule: Monday-Friday, 9AM-5PM

Compensation: $62,500 - $65,500 per year, dependent on experience

Location: New York, NY 10002

Benefits:

  • Generous time off, including 4 weeks of vacation
  • Medical, dental, and vision insurance
  • Discounted commuter benefits
  • Life insurance and long-term disability
  • Eligibility for Federal Student Loan Repayment Program
  • Training and other additional voluntary benefits

To be considered for this role, please submit your resume and salary requirements. Visit our website at www.lesc.org for more information.

Requirements:

  • Minimum of 2 years of case management and/or utilization review experience
  • Strong problem-solving and analytical skills to interpret statistical data
  • Excellent oral, written, organizational, and interpersonal communication skills
  • Ability to communicate effectively with senior leadership and other stakeholders
  • Demonstrated ability to collaborate with peers and senior leadership on project assignments and group presentations
  • OASAS CASAC Certification (with Bachelor's Degree)
  • Other QHP credentials, such as LMSW, LMHC, LMSW-LP, or MHC-LP (with Master's Degree)
  • Master's Degree in Social Work or related field
  • In-depth knowledge of HIPAA, OASAS, and 42 CFR regulations
  • Working knowledge of quality assurance and utilization review systems
  • Computer literacy, including proficiency in Microsoft Office Suite and HER
  • Experience working with diverse populations
  • Competency in written, interpersonal, verbal, and computational skills to present and document records
  • Ability to work independently

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