[Hiring] Utilization Management Correspondence RN @Amerihealth Caritas

Role Description

Under the direction of the Utilization Management Operations Administrative Supervisor, the Utilization Management (UM) Correspondence Registered Nurse (RN) is responsible for:

• Creation, writing, editing, and completion of all utilization management review adverse decision notices and additional informational letters in accordance with state/plan requirements.
• Oversight of behavioral and physical health approval and denial letters for Medicaid, Medicare, and the Exchange.
• Using regulatory, accreditation, and departmental standards to ensure letters provide appropriate justification for authorizing services and denying services when guidelines are not met.
• Maintaining current knowledge of laws, regulations, DHS/NCQA requirements, and policies relevant to the organizational unit’s business.
• Reporting noncompliance or trends to leadership as appropriate.

Work Arrangement

• Remote role.
• Monday through Friday from 8:00a EST to 5:00p EST.
• Availability to work rotating weekends based on business needs is required.
• Must work 4 out of 10 holidays to include Thanksgiving and Christmas (rotating).

Responsibilities

• Navigates the documentation system (currently JIVA) and understands the utilization management review process for medical necessity determinations.
• Ensures that all languages meet the CFR (Code of Federal Regulations) requirements (i.e., Flesh Kincaide level, grammar, readability, and accurate dates).
• Ensures the translation process is followed if the member’s language preference is other than English.
• Collaborates with Medical Directors to update rationale to meet all regulatory requirements.

Qualifications

• Bachelor’s Degree required.
• Must be a Registered Nurse.
• Minimum of 3 years of diverse and independent clinical practice experience as a Registered Nurse.
• Minimum of 2 years of experience conducting inpatient, outpatient, and post-acute utilization management reviews for a payor.
• Utilization management review experience in a managed care organization.
• Experience applying NCQA, individual state contract, and CMS regulatory standards throughout the review process.
• Quality assurance or auditing experience in a managed care organization or acute care setting.

Licensure

• Active and unencumbered Enhanced Nurse Licensure Compact (eNLC) required.

Skills and Abilities

• Demonstrated ability to meet productivity measures in a high-volume work environment.
• Strong analytical, data interpretation, and written and verbal communication skills.
• Decision-making skills with the ability to identify problems and recommend solutions.
• Detail-oriented and process-driven.

Benefits

• Flexible work solutions including remote options and hybrid work schedules.
• Competitive pay.
• Paid time off including holidays and volunteer events.
• Health insurance coverage for you and your dependents on Day 1.
• 401(k).
• Tuition reimbursement and more.