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AmeriHealth Caritas · 1 month ago

Utilization Management Reviewer

Washington, DC

Full-time

Hybrid

Mid Level

$84K/yr - $114K/yr

3+ years exp

AmeriHealth Caritas is a mission-driven organization focused on delivering comprehensive health care solutions. The Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient 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 Medicaid industry standards

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

Qualification

Registered Nurse licenseUtilization review processesElectronic Medical Record SystemsInterQual criteriaPrior authorizations experienceMS Office proficiencyClinical judgmentCommunication skillsTeam collaboration

Required

Associate's Degree in Nursing (ASN) required

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

Active and unencumbered Registered Nurse license in the District of Columbia

Valid and current driver's license required

Proficiency in 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

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

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