Job Description

Job Description:

We are seeking an experienced Case Manager, UM, for a contract opportunity with a leading healthcare organization. This role involves providing case management services to members, ensuring medical necessity, and coordinating care in alignment with regulatory and clinical criteria.

Responsibilities:

• Provide case management services for assigned member caseloads.

• Perform risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments using InterQual/MCG criteria.

• Identify medical, psychological, and social issues requiring intervention.

• Partner with PCPs and providers to coordinate treatments, services, and authorizations; negotiate rates with non-partner providers as needed.

• Ensure access to a full continuum of network and community resources to support health and recovery.

• Document determinations, notifications, interventions, and encounters per established standards and regulatory guidelines.

• Report and escalate questionable healthcare services.

• Serve as a clinical resource for the care team to maximize quality of care and manage costs effectively.

• Assist in identifying opportunities and facilitating alternative care options.

• Occasional overtime as required.

• Product knowledge includes Medicare Advantage and Medicaid.

Requirements:

• Active RN license (any state).

• Experience in managed care, case management, alternative care options, and discharge planning.

• Certified Case Manager preferred, not required.

• InterQual and/or Milliman knowledge.

• Familiarity with CMS and NYSDOH regulations governing medical management in managed care.

• Relevant clinical work experience.

• Proficiency with Outlook (intermediate), Word, Excel, PowerPoint, and Adobe Acrobat.

• Strong critical thinking, assessment, and documentation skills.

• Ability to manage large caseloads and thrive in a fast-paced environment.

Key Skills:

• Case Management

• Utilization Management (UM)

• InterQual/MCG Criteria

• Medicare Advantage and Medicaid

• Care Coordination and Discharge Planning

Pay Range:

$35-42 per hour

We understand rate is an important factor in your job search and encourage you to apply even if your desired compensation falls outside this range. The final rate is determined based on several factors including relevant experience, education, certifications, and market conditions.

Benefits:

Our comprehensive benefits package includes:

o Medical insurance

o Dental insurance

o Vision insurance

o 401(k) retirement savings plan

Contact:

Karrie Ruch

kruch@jacobsongroup.com

Refer a Colleague:

Do you know someone who would be interested in this project? Submit your referral directly by emailing the Jacobson contact listed above or submitting them through this form. If your referral is hired for a contract assignment and meets all other eligibility criteria, you will receive a referral bonus!

Equal Opportunity Employer:

The Jacobson Group is committed to fostering an inclusive and equitable workplace that reflects the diverse communities we serve. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status or any other protected characteristic as defined by applicable law. We believe that diversity of thought, background and experience strengthens our team and drives innovation. All employment decisions are based on qualifications, merit and business needs.

If you require a reasonable accommodation to complete the application process or participate in an interview, please contact us at HR@jacobsononline.com or +1 (800) 466-1578

Equal Opportunity Employer:

The Jacobson Group is committed to fostering an inclusive and equitable workplace that reflects the diverse communities we serve. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status or any other protected characteristic as defined by applicable law. We believe that diversity of thought, background and experience strengthens our team and drives innovation. All employment decisions are based on qualifications, merit and business needs.

If you require a reasonable accommodation to complete the application process or participate in an interview, please contact us at HR@jacobsononline.com or +1 (800) 466-1578 to make a request. +1 (800) 466-1578 to make a request +1 (800) 466-1578 to make a reques +1 (800) 466-1578 to mak +1 (800) 466-1578 to +1 (800) 466-1578

Job Tags

Similar Jobs