Healthfirst

This position will be responsible for directing, overseeing and managing the Utilization Management program and operations. This position will also have direct responsibility for all relative program development, implementation and monitoring in accordance with business needs as well as Local, State and Federal standards. This position will be considered a subject matter expert in all things related to Utilization Management to our business leaders and stakeholders.

Duties/Responsibilities:

·        Provides oversight of and leadership with minimal guidance to their assigned teams

·        Develops and monitors appropriate metrics in order to monitor department performance

·        Drives initiatives and activities to reduce preventable admissions and readmissions across targeted lines of business

·        Drives process improvements to ensure that requested services are reviewed and either approved or denied based on medical necessity and appropriateness in accordance with HF Policy and State & Federal guidelines/regulations

·        Collaborates with other departments at Healthfirst to improve health outcomes and quality measure performance

·        Continuously improves effectiveness and efficiency of processes and programs

·        Provides information and knowledge to team, including community access to resources, housing, support programs and other (NYC) based community programs

·        Develops, implements and monitors new care management programs relative to applicable lines of business and product/benefit changes

·        Coordinates and advises other stakeholders and business owners of clinical and operational initiatives

·        Evaluates departmental operations with a focus on process improvement

·        Works as a liaison with external organizations to assure lines of communication are in place for member and vendor engagement

·        Participates and represents Utilization Management on business implementation of new products

·        Advocates for Plan public policy by actively participating as the clinical voice on various clinical committees and other clinical policy workgroups

·        Additional duties as assigned

 

Minimum Qualifications:

·        Bachelor’s degree

Preferred Qualifications:

·        BSN or RN or BS/BA in other health related field

·        Master degree in health related degree

·        Experience as a mid-senior management in the field of medical care management, utilization management or other healthcare management

·        Demonstrated strategic thinking with strong collaboration skills to work effectively with a variety of internal personnel and external organizations, as warranted

·        Experience in process improvement, ability to devise innovative and practical solutions to solve problems

·        Experience with complex data system

 

Compliance/Regulatory Duties & Responsibilities:

·        Responsible for monitoring all work products to ensure it is in compliance with all Local, State and Federal standards.

 

Required License/Certification: n/a

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $154,600 - $236,555

• All Other Locations (within approved locations): $127,500 - $195,075

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.