Utilization Management Reviewer

About the Role

The day-to-day responsibilities of this role will involve reviewing provider requests, gathering necessary medical documentation, and applying professional judgment to assess the appropriateness of services. The reviewer will also identify care coordination opportunities and ensure compliance with medical policies, regulatory requirements, and patient needs. In a fast-paced environment, the reviewer will need to meet established turnaround times, quality benchmarks, and efficiency metrics.

AmeriHealth Caritas is committed to delivering high-quality patient care, and the Utilization Management Reviewer will be essential in achieving this goal. With a strong focus on clinical excellence, care coordination, and regulatory compliance, this role offers a unique opportunity for professionals to make a meaningful impact on patient outcomes.

What You Will Do

• 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
• Apply medical and behavioral health guidelines to authorize services, ensuring they meet the patient’s needs in the least restrictive and most effective manner
• Stay up-to-date with federal, state, and organizational regulations, consistently applying them in decision-making
• Participate in quality improvement initiatives to enhance the utilization management process

What We Are Looking For

• Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred
• 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
• 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 a payor (e.g. Medicaid, Medicare or commercial plan) preferred
• Active and unencumbered NLC required
• Proficiency using 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
• Working knowledge of InterQual criteria
• Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment

Nice to Have

• Experience with MS Office, including Excel, Word, Outlook, and Teams
• Ability to type with speed and accuracy
• Strong analytical and problem-solving skills
• Excellent communication and interpersonal skills

Benefits and Perks

• Competitive salary and benefits package
• Opportunity to work remotely and maintain a healthy work-life balance
• Collaborative and dynamic work environment
• Professional development and growth opportunities
• Access to cutting-edge technology and tools
• Recognition and reward for outstanding performance
• Comprehensive health insurance and wellness programs
• Generous paid time off and holiday schedule
• Retirement savings plan and matching contributions

• Tip: Showcase your expertise in clinical guidelines, medical necessity evaluations, and care coordination, highlighting specific examples from your experience.
• Tip: Familiarize yourself with InterQual criteria and be prepared to discuss how you apply these guidelines in your utilization management reviews.
• Tip: Demonstrate your ability to work effectively in a fast-paced, remote environment, emphasizing your strong analytical and problem-solving skills.
• Tip: Prepare to discuss your experience with Electronic Medical Record Systems and your ability to efficiently document and assess patient cases.
• Tip: Be ready to provide specific examples of how you have improved patient outcomes through your utilization management reviews, highlighting your ability to communicate effectively with healthcare providers and patients.
• Tip: Research AmeriHealth Caritas and be prepared to discuss how your skills and experience align with the company’s mission and values.