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UM Case Manager - 100% Remote - Job Opportunity at Healthfirst

Remote, US
Full-time
Mid-level
Posted: February 20, 2025
Remote
USD 81,099 - 116,480 per year

Benefits

Comprehensive medical insurance with competitive coverage
Vision and dental plans included
401(k) retirement plan with company contributions
Life insurance coverage
Performance-based incentives and recognition programs

Key Responsibilities

Lead utilization management and care coordination for assigned member portfolio, ensuring optimal health outcomes while managing costs
Conduct comprehensive pre-certification reviews using InterQual/MCG criteria to validate medical necessity
Drive care plan development and implementation through multi-disciplinary collaboration
Perform strategic rate negotiations with non-network providers to optimize cost efficiency
Manage complex case documentation and reporting in compliance with regulatory requirements
Execute discharge planning and transitional care coordination to reduce readmissions

Requirements

Education

Bachelor's degree required, Master's preferred in related discipline

Experience

3+ years preferred in managed care or case management

Required Skills

InterQual and/or Milliman expertise Microsoft Office Suite proficiency Critical thinking and assessment capabilities Professional documentation skills Caseload management experience Knowledge of CMS and NYSDOH regulations

Certifications

RN, LPN, LMSW, LMHC, LMFT, LCSW, PT, OT, or ST license Certified Case Manager (preferred) CASAC (for substance abuse positions)
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Sauge AI Market Intelligence

Industry Trends

Healthcare organizations are increasingly prioritizing remote care management positions to support distributed healthcare delivery models The integration of value-based care principles is driving demand for skilled utilization management professionals Growing emphasis on data-driven decision making in care management is requiring enhanced technical competencies

Salary Evaluation

The offered salary range aligns with market standards, reflecting a 15-20% premium for specialized healthcare management skills. Regional variations consider cost-of-living differences, with NYC metro commanding higher compensation.

Role Significance

Typically operates within a team of 8-12 case managers, reporting to a UM Director or Clinical Operations Manager
Mid-level position with significant autonomy in clinical decision-making and direct impact on organizational cost management

Key Projects

Implementation of new care management protocols Cost containment initiatives through strategic utilization review Quality metric improvement programs Provider network optimization projects

Success Factors

Strong clinical judgment combined with business acumen Ability to balance member care quality with cost management objectives Excellence in stakeholder communication and collaboration Proficiency in healthcare regulatory compliance

Market Demand

High demand with projected 15% growth over next 3 years due to aging population and healthcare cost management priorities

Important Skills

Critical Skills

Clinical expertise in managed care environment Utilization review and medical necessity determination Healthcare regulations and compliance knowledge Case management and coordination skills

Beneficial Skills

Population health management perspective Value-based care program experience Healthcare analytics capabilities Quality improvement methodologies

Unique Aspects

Full remote work capability unusual for clinical role of this scope
Comprehensive integration of utilization management with care coordination
Dual focus on clinical outcomes and financial management

Career Growth

Typical progression to senior role in 2-3 years, management position in 4-5 years with demonstrated leadership capabilities

Potential Next Roles

Senior Case Manager UM Program Manager Clinical Operations Director Population Health Manager

Company Overview

Healthfirst

Healthfirst is a leading not-for-profit health insurer serving New York's diverse communities

Major regional player in managed care with strong focus on government programs and value-based care models
Dominant in Greater New York metropolitan area with expanding remote workforce capabilities
Mission-driven organization emphasizing work-life balance and professional development
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