After Hours Behavioral Health Clinical Care Utilization Management Reviewer

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 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.

Responsibilities

The After-Hours Behavioral Health (BH) Utilization Management (UM) Reviewer will be scheduled to work non-traditional hours to provide access to medical necessity determinations for urgent and contractually required coverage requests 24/7, 365 days a year.

Under the direction of the Supervisor, the After-Hours BH UM Reviewer is responsible for assisting members with appropriate specialized behavioral health care coordination and care management services by completing medical necessity reviews through the application of standard operating procedures and pre-determined criteria. Using clinical knowledge and experience, the BH UM Reviewer reviews the provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the BH UM Reviewer’s discretion to retain requests for additional information and/or request clarification when necessary.

The BH UM Reviewer uses their professional knowledge and judgment along with standardized criteria to evaluate the request to ensure that appropriate services are approved, and they will use standardized operating procedures to recognize care coordination opportunities and refer those cases to integrated care management as needed. The BH UM Reviewer will apply medical health benefit policy and medical management guidelines to authorize services. They are not permitted to deny a request for services; instead, they appropriately identify and refer requests to the Medical Director when required. The BH UM Reviewer ensures the treatment delivered is appropriate and meets the Member’s needs in the least restrictive, least intrusive manner possible while adhering to tight contractual turnaround times. The BH UM Reviewer maintains current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational business units and uses clinical judgment in their application.

Work Arrangement

• Please note this position is for after-hours between 12:00 AM EST to 8:00 AM EST, Tuesday through Sunday or Wednesday through Sunday.
• Remote role
• Must work 4 out of 10 recognized company holidays to include Thanksgiving and Christmas (rotating)

Education & Experience

• Registered Nurse candidates: Associate Degree in Nursing required; Bachelor Degree in Nursing preferred
• Licensed Social Worker candidates: Master Degree in Social Work required
• Minimum of 2 years of independent clinical practice experience assessing and treating individuals with mental health/substance use/co-occurring disorders in a partial hospitalization program (PHP), intensive outpatient program (IOP) and/or residential treatment program.
• Minimum of 3 years of utilization management experience for a payor (Medicaid or Medicare) required
• Experience working in a remote work environment required

Licensure

• Requirements for LSW: Active and unencumbered professional licensure/independent licensure: LPC, LCSW, LICSW, LISW, LCMHC, LMFT
• Must have ability to obtain additional licensure in OH, LA, NC, NH and DC within 12 months from date of hire
• Requirements for RN: Active and unencumbered RN license
• Must have ability to obtain additional licensure in OH, LA, NC, NH and DC within 12 months from date of hire

Skills & Abilities

• Proficiency in Microsoft Office, including Word, Excel, Teams, and Outlook
• Experience using Electronic Health Records
• Consistent and accurate typing skills
• Ability to communicate in a positive/professional manner both orally and written
• Strong problem-solving skills and decision making skills
• Strong organizational and time management skills
• Ability to follow detailed instructions with a high degree of accuracy
• Ability to work independently; complete tasks in the allotted time frame

Flexible work solutions including 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.