Clinical Care Reviewer Utilization Management

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.

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.

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

• Monday through Friday from 8:30 AM EST to 5:00 PM EST
• Must work 4 recognized company holidays to include Thanksgiving and Christmas (rotating)
• Weekends and overtime 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 as a Registered Nurse in outpatient surgery, Medical-Surgical, Critical Care, Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings
• Experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient, outpatient and/or post acute services
• Experience conducting utilization management reviews specific to a Medicare population across multiple states for a payer preferred

Licensure

• An active and unencumbered Registered Nurse (RN) license in the District of Columbia required

Skills and Abilities

• Competency in electronic health record (EHR) 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
• Ability to type with accuracy and speed

The range displayed in this job posting reflects the minimum and maximum for new hire salaries for the position in the Washington DC area. Within the range, individual pay is determined by additional factors, including, without limitation, job-related skills, experience, and relevant education, certifications, or training. AmeriHealth Caritas associates are eligible to participate in our annual incentive program and will also receive our benefits package, consisting of medical, vision, dental, life insurance, disability insurance, 401(k), paid time off and more. The targeted hiring range for this role is expected to be between $86,000.00 and $117,300.00 (or $41.35 and $56.39 per hour).

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.