Utilization Management Reviewer

Role Overview

Under the direction of a supervisor, the Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Utilization Management Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient’s needs in the least restrictive and most effective manner.

Work Arrangement

• Remote role
• Monday through Friday from 8:00 AM to 5:30 PM EST
• 4 out of 10 recognized company holidays to include Thanksgiving and Christmas (rotating)
• Weekends based on business need

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

Education & Experience

• Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred
• 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
• Experience conducting utilization management reviews for an insurance company (e.g. Medicaid, Medicare or commercial plan) is preferred

Licensure

• 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

Skills and Abilities

• 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

Your career starts now. We are looking for the next generation of healthcare leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. We want to connect with you if you want to make a difference. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, 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.