Care Manager, Utilization Management (NYCE)

Experteer Overview In this role you support quality of care and cost containment within the department. You will perform utilization management to coordinate care delivery and ensure medical appropriateness for admissions, post-acute requests, and selected procedures. By collaborating with an interdisciplinary team, you help members achieve optimal health outcomes through planning and review aligned with established guidelines and contracts. You will engage in case reviews, documentation, and referrals to ensure timely, appropriate care and cost efficiency. This position offers a meaningful opportunity to impact patient care within a managed care framework. Compensation / Benefits • Evaluate medical necessity using MCG, CMS Guidelines, and internal policies. • Identify at-risk members and refer to care management or disease management as needed. • Assess needs and coordinate care using approved criteria with member/family discussions. • Maintain utilization time frames per regulatory guidelines including initial determinations and notifications. • Provide case reviews and ensure timely communication with facilities, members, and providers. • Determine coverage eligibility based on member contracts and collaborate with providers on problem solving. • Prepare and present clinical detail to Medical Director for final case decisions. • Identify cost-reduction opportunities and ensure cost effectiveness (e.g., reinsurance reporting). • Refer questionable quality issues or inappropriate hospitalizations to Medical Director for intervention. Tasks • Associate Degree in Nursing; Bachelor's preferred • RN with active, unrestricted license OR LPN with active, unrestricted license • MCG Certification preferred • 4-6+ years of clinical experience • Managed care experience • Post-acute facility experience • Care management experience • Ability to work weekends/holidays on a rotating schedule • Excellent verbal, written, and interpersonal communications • Ability to screen and stratify members for care management • Ability to manage a caseload and apply CMSA/EH policies • Ability to create and execute care plans and document per policies • Professional communication with all parties involved in the member's care plan Key requirements •