Utilization Manager

3 weeks ago


New York, New York, United States PROMESA R.H.C.F. Full time
Job Title: Utilization Manager

Promesa R.H.C.F. is seeking a highly skilled Utilization Manager to join our team. As a key member of our healthcare team, you will be responsible for ensuring that our patients receive the highest level of care while also meeting the requirements of managed care organizations.

Key Responsibilities:
  • Collaborative Communication: Develop and maintain strong relationships with external case managers, managed care organizations, and other healthcare professionals to ensure seamless communication and data exchange.
  • Medical Necessity Reviews: Conduct thorough medical necessity reviews to ensure that patients receive the necessary care and services, while also meeting the requirements of managed care organizations.
  • Liaison and Coordination: Act as a liaison between our residential program and managed care organizations to facilitate the reimbursement process and ensure that patients receive the necessary care and services.
  • Denial and Appeal Management: Identify and refer MCO denials and non-covered medical services to the directors for appeal determination and next steps.
  • Discharge Planning: Collaborate with clinicians to identify discharge needs and coordinates with Social Services in the creation and implementation of a discharge/transfer plan.
  • Post-Discharge Follow-up: Coordinates post-discharge follow-up care with selected patients and community providers.
Requirements:
  • Experience: Minimum of 2 years of case management and/or utilization review experience.
  • Education: Associate degree required; bachelor's Degree preferred.
  • Skills: Strong problem-solving and advanced analytical skills necessary to read, understand, interpret and analyze statistical data. Excellent oral, written, organizational and interpersonal communication skills.

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