Supervisor Utilization Management Review

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. Discover more about us at www.amerihealthcaritas.com.

Role Overview

The Utilization Management Review Supervisor manages a remote team of up to 15 Utilization Management Reviewers who process prior authorization requests and concurrent reviews for Medicaid members in the Delaware market. In this role, you will provide clinical, technical, and operational guidance to staff, oversee workflow and inventory, and ensure the team meets its goals through performance monitoring, auditing, coaching, and training.

Work Arrangement

• Remote role
• Monday through Friday, 8:00a EST to 5:00p EST
• Must be able to work weekends and evenings based on business needs
• Must be able to work 4 to 5 recognized company holidays to include Thanksgiving and Christmas (rotating)

Responsibilities

• Team supervision: Provide daily oversight, support, and direction to a remote team of Utilization Management Reviewers
• Clinical and technical support: Offer guidance on clinical and technical aspects of the review process
• Operational oversight: Manage daily operations, including monitoring work assignments and adjusting based on staffing and request volume
• Performance management: Ensure the team meets operational goals through auditing, coaching, and training
• Inventory and workflow management: Oversee the inventory of prior authorization requests and manage workflow to ensure timely processing
• Goal achievement: Monitor team productivity and other performance indicators to help the team achieve its operational goals

Education and Experience

• Associate Degree in Nursing required; Bachelor Degree in Nursing preferred
• Minimum of 5 years of diverse independent clinical practice experience in an acute care setting
• Minimum of 3 years of experience performing prior authorization and concurrent reviews for a managed care organization
• Experience leading a team of remote Utilization Management Reviewers

Licensure

• Current and unencumbered Registered Nurse licensure in Delaware or Nursing Licensure Compact (NLC) required

Skills and Abilities

• Strong analytical and problem-solving skills to review cases and identify trends
• A high level of attention to detail to ensure accuracy in reviews
• Excellent communication is required for interacting with staff, healthcare providers, and potentially members
• Proficiency using Microsoft Office applications to include Outlook, Word, Excel, Teams, and PowerPoint
• Familiarity with Electronic Medical Record (EMR) and healthcare documentation software
• Proficiency with InterQual and proven track record of applying the criteria to complex Medicaid cases

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.