Utilization Manager

Company: LESC
Location: New York
Posted on: September 28, 2024

Job Description:

Description:MAJOR DUTIES:In concert with the agency's mission and goal of sustaining high quality care/service delivery to persons served, the Utilization Manager works to assist CASAC Counselors and supervisory staff as needed with assuring compliance with external and internal utilization review/quality and appropriateness requirementsThe Utilization Manager is responsible for the day to day functions of collaborative communication with external case managers at referring provider facilities and/or managed care organizations (MCO) for data collection, interpretation and certification/recertification from third party payers at pre-admission through discharge, ongoing medical necessity reviews and interdisciplinary team support with respect to MCO requisitesIn addition, this position is responsible for having a thorough understanding of patient treatment plans through participative discussions with the care plan (interdisciplinary) team, identifying and referring requests for services to the Medical Director when guidelines are not met and reviewing residential services requiring MCO approvalObtaining the required pre-authorization/certification of specified services from the MCO and communicating end of benefit status and/or reimbursement changes to Finance and others as deemed necessaryConducting ongoing medical necessity reviews, which may be pre-service, concurrent and/or retrospective in nature, by evaluating clinical data and submitting appropriate documentation to update the patient/resident's status to the MCO as scheduledActing as a liaison between the residential program and the MCO to better facilitate the reimbursement processReferring MCO denials and non-covered medical services to the directors for appeal determination and next stepsConducts timely and complete quality and appropriateness reviews on a representative sample of treatment records for residential service sitesProvides Supervisory support to CASAC Counselors and Peer Workers as needed with supervisory guidance from Management/Leadership TeamMonitors and evaluates ongoing audit for chartProvides direct care services to clients as neededAssists with the maintenance of the agency's OASAS reviews and CARF accreditation for the program, i.e., standards review and conformance auditingPerforms other duties as assignedSCHEDULE: Monday-Friday 9AM-5PMRATE: $62,500 - $65,500 / year (dependent on experience)LOCATION: NY, NY 10002We offer excellent benefits including:Generous time off that includes 4 weeks of vacationMedical, Dental, and Vision InsuranceDiscounted Commuter benefitsLife insurance & Long term disabilityEligible for Federal Student Loan Repayment ProgramTraining and other additional voluntary benefitsTo join our diverse team, please include salary requirements with your resume/application submission. Please visit us at www.lesc.org EEO Minorities/Women/Disabled/VetRequirements:QUALIFICATIONS - EDUCATION AND PROFESSIONAL EXPERIENCE:Minimum of 2 years of case management and/or utilization review experienceStrong problem-solving and advanced analytical skills necessary to read, understand, interpret and analyze statistical dataExcellent oral, written, organizational and interpersonal communication skills Ability to communicate effectively with senior leadership as well as other clinical/non clinical directors, managers, staff, consultants and MCOsDemonstrated ability to effectively collaborate with peers and senior leadership on project assignments and group presentationsOASAS CASAC Certification (with Bachelor's Degree)Other QHP credential 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 on HIPAA, OASAS, and 42 CFR regulationsWorking knowledge of quality assurance and utilization review systemsComputer literacy including proficiency in Microsoft Office Suite and HERExperience working directly with people from diverse racial, ethnic, and socioeconomic backgroundsCompetency in written, interpersonal, verbal, and computational skills to present and document records in accordance with program standardsAbility to work independentlyCompensation details: 62500-65500 Yearly SalaryPI98fc8b460fb8-25660-34494836

Keywords: LESC, New York , Utilization Manager, Executive , New York, New York