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AmeriHealth Caritas · 1 day ago

After Hours Utilization Management Reviewer

United States

Full-time

Remote

Mid Level

3+ years exp

AmeriHealth Caritas is a mission-driven organization with over 30 years of experience in healthcare solutions. They are seeking an After Hours Utilization Management Reviewer who will evaluate medical necessity for inpatient and outpatient services, ensuring compliance with clinical guidelines and regulatory requirements while working non-traditional hours.

Health CareInformation Technology

H1B Sponsor Likely

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

Utilization management experienceClinical practice experienceNurse Licensure CompactElectronic Medical Record SystemsMS Office proficiencyMedical necessity criteriaCare coordinationRegulatory complianceCritical evaluation skillsAccurate typing skills

Required

Associate's Degree in Nursing (ASN) required

Minimum of 3 years of diverse and independent clinical practice experience

Minimum of 2 years of current experience performing prior authorization and concurrent reviews for in and outpatient services using evidence-based criteria

Must have utilization management review experience in a managed care organization

Current and unencumbered Nurse Licensure Compact (NLC)

Current driver's license

Must be able to obtain licensure in all markets across the enterprise to include the District of Columbia

Proficiency using Electronic Medical Record Systems to efficiently document and assess patient cases

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 pivot between high priority tasks to meet productivity standards in a fast-paced, high-volume utilization review environment

Ability to gather and critically evaluate clinical information and criterion

Accurate typing skills

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

Preferred

Bachelor's Degree in Nursing (BSN) preferred

Benefits

Flexible work solutions include remote options

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

Company

AmeriHealth Caritas

Glassdoor3.4

AmeriHealth Caritas is the health care solutions provider for those in most need and the chronically ill.

Founded in 1982

Philadelphia, Pennsylvania, USA

10001+ employees

http://www.amerihealthcaritas.com

H1B Sponsorship

AmeriHealth Caritas has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (18)

2024 (17)

2023 (12)

2022 (14)

2021 (4)

2020 (11)