Amida Care · 4 months ago
Manager of Clinical Services - Utilization Management
New York, NY, US
Full-time
Onsite
Senior Level
$103K/yr - $128K/yr
5+ years expAmida Care is the largest Medicaid HIV Special Needs Plan in NY, focused on delivering comprehensive care and coordinated services for positive health outcomes. The Manager of Clinical Services – Utilization Management will oversee UM activities and staff, ensuring compliance with regulatory guidelines and managing appeals and denials.
Child CareHealth CarePharmaceutical
Responsibilities
Provide regular oversight of Medical and Gender Affirming Services (GAS) UM processes ensuring all regulatory guidelines are followed
Track and process all medical/GAS UM appeals
Process all UM actions for Fair Hearing and External Appeals
Provide clinical review of Health Services complaints, working closely with the A&G department and the Manager of Clinical Services Operations
Develop and maintain comprehensive monitoring processes and tools related to authorizations, appeals, quality, case management, interrater reliability and data entry
Perform regular, proactive internal auditing to ensure that documentation, UM letters, controls and processes are appropriate and aligned with regulations and internal policies and procedures
Create monitoring reports, and follow up on findings and recommendations, i.e. length of stay reports
UM Point of contact for Medical Delegated vendor
Review all medical utilization management (UM) denials and appeals received from Medical UM vendor prior to final determination by the Medical Director
Review and process claims appeal as appropriate
Provide guidance, support and oversight into UM protocols, benefits and guidelines to the UM staff
Participate in the implementation and monitoring of corrective action plans from internal and external audits related to UM
Assist with report preparation for the Delegated Vendor Oversight and Quality Management Committees
Perform other duties as assigned
Qualification
Required
Registered Nurse (RN) license in New York State
5 years' experience in a health plan offering Medicaid and/or Medicare Advantage plans
General knowledge of Medicaid Managed Care
Demonstrate intermediate PC skills using word, PowerPoint and Excel
Exhibit ability to work independently with attention to detail
Exhibit a strong commitment to objectivity
Exhibit a strong commitment to maintaining the integrity and effectiveness of the Health Services Department
Demonstrate interpersonal and verbal communication skills
Demonstrate ability to liaison with other departments
Demonstrate ability to research facts regarding compliance issues and incidents
Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts
Demonstrate appropriate behaviors in accordance with the organization's vision, mission, and values
Company
Amida Care
Amida Care is an organization providing healthcare, meals, advocacy, research and social services.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Doug Wirth
President/CEO
Alex Fontanez
Associate Director of Partnerships & Ombudsman
Recent News
2025-11-19
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