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AmeriHealth Caritas · 4 months ago

Utilization Management Reviewer

United States

Full-time

Remote

Mid Level

3+ years exp

AmeriHealth Caritas is a mission-driven organization focused on delivering comprehensive healthcare solutions. The Utilization Management Reviewer evaluates medical necessity for services, ensuring compliance with clinical guidelines and regulatory requirements while collaborating with healthcare providers to optimize patient care.

Health CareInformation Technology

Responsibilities

Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines

Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care

Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines

Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions

Identify and escalate complex cases requiring physician review or additional intervention

Ensure compliance with industry standards, including Medicare, Medicaid, and private payer requirements

Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment

Qualification

Registered Nurse (RN) licenseUtilization review processesEvidence-based criteria applicationElectronic medical record (EMR)MS Office proficiencyAccurate typing skillsCommunication skills

Required

Associate's Degree in Nursing (ASN) required

Minimum of 3 years of diverse independent clinical practice experience to include Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings

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

An active and unencumbered Registered Nurse (RN) license under the Nursing Licensure Compact (NLC)

Ability to obtain additional licensure across the enterprise to include the District of Columbia

Valid Driver's License

Competency in electronic medical record (EMR) documentation and charting

Proficiency using MS Office to include Word, Excel, Outlook and Teams

Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance

Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment

Maintains a strong working knowledge of federal, state, and organizational regulations to ensure consistent application in the review process

Accurate typing skills