Utilization Management Reviewer

Related keywords: remote job registered nurseremote job nursingremote job nurse

Position Overview

The Utilization Management Reviewer role at AmeriHealth Caritas District of Columbia focuses on evaluating medical necessity for both inpatient and outpatient services. Reviewers ensure that the appropriateness of treatment aligns with clinical guidelines, regulatory requirements, and the specific needs of patients. This position plays a crucial role in the medical review process, requiring attention to detail, strong decision-making skills, and the ability to analyze complex medical information.

Responsibilities

In this role, the Utilization Management Reviewer is responsible for several key tasks, which include:

• Conducting utilization management reviews to assess medical necessity and appropriateness of care
• Collaborating with healthcare providers to facilitate timely authorizations and enhance patient care
• Analyzing medical records and clinical data to ensure compliance with regulatory and payer guidelines
• Effectively communicating determinations and providing clear, evidence-based rationales for both approval and denial decisions
• Identifying and escalating complex cases for physician review when necessary
• Maintaining compliance with Medicaid industry standards and relevant regulations
• Meeting established performance metrics and turnaround times in a high-volume review environment

Work Environment

This is a remote position, allowing flexibility in work arrangements. The typical work hours are from Monday through Friday, 8:00 AM to 5:00 PM. The company recognizes four major holidays, including Thanksgiving and Christmas, and there may be weekend work based on business needs.

Required Skills and Qualifications

Candidates should possess the following qualifications and skills:

• Education: An Associate’s Degree in Nursing (ASN) is required, while a Bachelor’s Degree in Nursing (BSN) is preferred.
• Experience: A minimum of three years of clinical experience as a Registered Nurse in settings such as Intensive Care Units (ICU), Emergency Departments (ED), Medical-Surgical (Med-Surg) units, Skilled Nursing Facilities (SNF), rehabilitation, or home health care is necessary. Additionally, candidates should have at least two years of experience applying evidence-based criteria, such as InterQual, for prior authorizations and concurrent reviews.
• Licensure: Candidates must hold an active and unencumbered Nursing License (NLC).
• Technical Proficiency: Proficiency in using Electronic Medical Record Systems and strong skills in Microsoft Office tools, including Excel, Word, and Outlook.
• Soft Skills: Successful candidates should demonstrate effective communication abilities, the ability to work efficiently under pressure, and the ability to type quickly and accurately.

Salary and Benefits

While the specific salary for the Utilization Management Reviewer role is not detailed in the description, it is suggested that AmeriHealth Caritas offers competitive pay as part of their comprehensive benefits package. Benefits include:

• Flexible work solutions, including remote options and hybrid schedules
• Paid time off and holidays
• Health insurance coverage for employees and dependents from Day 1
• 401(k) plan with employer match
• Tuition reimbursement programs to support continuing education
• Opportunities to participate in volunteer events

These benefits reflect the organizational commitment to employee well-being and support other avenues for professional growth.

About the Company

AmeriHealth Caritas is rooted in a mission-driven philosophy dedicated to improving health outcomes in communities. Headquartered in Newtown Square, the organization has over 30 years of experience in healthcare solutions. AmeriHealth Caritas provides a wide array of services, including integrated managed care products, pharmaceutical benefit management, behavioral health services, and more. As a leader in healthcare, AmeriHealth Caritas is looking to attract committed and talented individuals who share the vision of delivering quality care and enhancing health across communities.

To find out more about AmeriHealth Caritas, candidates are encouraged to explore their website and learn about their initiatives and commitment to public health.

This job offer was originally published on himalayas.app