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Healthfirst Case Manager, UM Applied Behavior Analysis - Remote in Home Office, Massachusetts

The Case Manager, Utilization Management coordinates the care plan for assigned members and conducts pre-certification, concurrent review, and case management as assigned for members requesting services, including Applied Behavior Analysis. The Case Manager, Utilization Management is also responsible for efficient utilization of health services and optimal health outcomes for members, as well as meeting designated quality metrics.

Working knowledge of Autism Spectrum Disorder and Applied Behavior Analysis

Position is 100% remote

  • Provides case management services for assigned member caseloads which includes: Pre-certification, performing risk-identification, pre-service concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments requests and service utilizations for services including Applied Behavior analysis based on clinical documentation, regulatory, and MCG criteria

  • Assessment - identifying medical, psychological, and social issues that need intervention.

  • Coordination - partnering with PCP and other medical providers to coordinate treatments, collateral services, and service authorizations.

  • Ensures appropriate access and utilization of a full continuum of network and community resources to support health and recovery

  • Documenting - documenting all determinations, notifications, interventions, and telephone encounters in accordance with established documentation standards and regulatory guidelines.

  • Reports and escalates questionable healthcare services

  • Meets performance metric requirements as part of annual performance appraisals

  • Monitors assigned case load to meet performance metric requirements

  • Functions as a clinical resource for the multi-disciplinary care team in order to maximize HF member care quality while achieving effective medical cost management

  • Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments- Additional duties as assigned

Minimum Qualifications:

  • RN, LPN, LMSW, LMHC, LMFT and/or LCSW license

  • Working knowledge of Autism Spectrum Disorder and Applied Behavior Analysis

Preferred Qualifications:

  • Board Certified Behavior Analyst

  • Master’s degree in a related discipline

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

  • Certified Case Manager

  • Knowledge of Centers for Medicare & Medicaid Services (CMS) or New York State Department of Health (NYSDOH) regulations governing medical management in managed care

  • Relevant clinical work experience

  • Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills.

  • Demonstrated critical thinking and assessment skills to ensure member care plans are followed.

  • Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

  • Demonstrated professional writing, electronic documentation, and assessment skills.

Since we care so greatly about our employees' and members' wellbeing, Healthfirst has implemented various COVID-related health and safety requirements for our workforce. Employees are expected to follow the Company’s current COVID-19 or other infectious disease health and safety protocols, including local requirements, which may include sharing information regarding your vaccine status and mask wearing. Protocols may change in the future with the evolving public health landscape. Healthfirst will consider accommodation requests as required by applicable law.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to 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.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

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All hiring and recruitment at Healthfirst is transacted with a valid “” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.