You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking a dedicated Care Manager to perform utilization management activities. This role involves evaluating medical necessity, coordinating comprehensive care, and interacting with various healthcare providers to ensure effective delivery of services.
Key Responsibilities
- Conduct hospital admission certification, continued stay review, discharge planning, and out-patient services review following established policies.
- Evaluate medical necessity, appropriate level of care, and length of stay using evidence-based criteria.
- Accurately document all reviews, clinical findings, and actions in the UM clinical system.
- Identify cases needing physician advisor review and manage medical necessity appeals.
- Ensure delivery of quality healthcare and services for members requiring care management.
- Collaborate with members’ PCP and other providers to approve care or refer cases as needed.
- Monitor utilization trends and potential member needs through data reports.
- Evaluate member needs from referred cases.
- Assist other departments in resolving utilization management issues.
- Ensure compliance with regulatory agency requirements in all Utilization Management activities.
- Participate in Medical Management grand rounds with the Physician Advisor.
- Perform additional duties as assigned.
Qualifications
- Undergraduate degree or diploma/certificate aligned with licensure.
- A minimum of two to five years clinical experience in an acute or applicable care setting.
- UM/UR experience in managed care or hospital setting required.
- Strong knowledge of clinical guidelines (e.g., InterQual or Milliman Care Guidelines).
- New York State license as Registered Nurse, License Practical Nurse, or Physical Therapist.
Skills
- Excellent communication and team collaboration skills.
Additional Requirements
This is a hybrid role with a Monday to Friday schedule from 9 AM to 5 PM.
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
Required Employment / Compliance Language
This job designation requires working in compliance with all applicable regulations and guidelines.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
