Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, referrals, and other plan services. Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions Collaborates with medical staff and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems Develops and analyzes operational and analytical reports to monitor and track operational efficiency Properly documents utilization management activities and rationale for all decisions in electronic medical records systems Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management

Minimum Qualifications:

Associates degree RN, LPN, LMSW, LMHC, LCSW, or any other relevant clinical license Work experience demonstrating verbal and written communication skills Experience working independently in a fast-paced environment that requires problem solving skills and handling multiple priorities simultaneously Experience with Microsoft Office Suite applications including

Excel, Word, Power Point and Outlook Preferred Qualifications:

BSN 5+ years of progressive clinical experience in managed care, LTSS, home health, or community-based care, 3+ years demonstrated leadership experience. Strong expertise in New York State Medicaid LTSS and utilization management, with advanced ability to interpret UAS-NY/Community Health Assessment (CHA) findings and translate NYS medical-necessity criteria into consistent, clinically sound, and compliant LTSS determinations. Proven experience leading clinical teams, providing oversight of complex and high-risk cases, and driving consistency and quality in utilization decisions. Demonstrated ability to monitor clinical and operational performance, identify trends and opportunities for improvement, strengthen workflows and decision-support practices, and ensure regulatory and audit readiness. Strong collaboration skills with Medical Directors, Care Management, Appeals, Compliance, Operations, and other key stakeholders. CCM, ACM, or comparable certification preferred. Additional duties as assigned Hiring Range

•: Greater New York City Area (NY, NJ, CT residents): $116,800 - $168,810 All Other Locations (within approved locations): $99,700 - $148,325 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.

Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.