[Hiring] Utilization Management Reviewer @Amerihealth Caritas

Role Description

Our Utilization Management Reviewers evaluate medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires:

• Reviewing provider requests and gathering necessary medical documentation.
• Making determinations based on clinical criteria.
• Assessing the appropriateness of services and identifying care coordination opportunities.
• Ensuring compliance with medical policies.
• Escalating cases to the Medical Director when necessary.
• Applying medical and behavioral health guidelines to authorize services.
• Maintaining a strong working knowledge of federal, state, and organizational regulations.
• Meeting productivity expectations including established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment.

Work Arrangement:

• Monday through Friday, 8:00 AM to 5:00 PM
• Will work some recognized company holidays to include Thanksgiving and Christmas (rotating)
• Weekends based on business needs

Qualifications

• Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred.
• Minimum of 3 years of diverse clinical experience as a Registered Nurse in an Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation or Long-Term Acute Care (LTAC), home health care, or medical office setting.
• Minimum of 2 years of experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient and/or outpatient services.
• Experience conducting utilization management reviews for a payor (e.g. Medicaid, Medicare or commercial plan) preferred.

Requirements

• Active and unencumbered Registered Nurse license required.
• Active and unencumbered Nurse Licensure Compact (NLC) preferred.
• Ability to obtain additional RN licensure across the enterprise including the District of Columbia (for select teams).

Skills and Abilities

• Proficiency using Electronic Medical Record Systems to efficiently document and assess patient cases.
• Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance.
• Working knowledge of InterQual criteria.
• Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment.
• Proficiency using MS Office to include Excel, Word, Outlook, and Teams.
• Ability to type with speed and accuracy.

Benefits

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