Utilization Management Correspondence RN

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.

Role Overview

Under the direction of the Utilization Management Operations Administrative Supervisor, the Utilization Management (UM) Correspondence Registered Nurse (RN) is responsible for creation, writing, editing and completion of all utilization management review adverse decision notices and any additional informational letters in accordance with the appropriate state/plan requirements, within required timeframes.

The UM Correspondence RN has oversight of behavioral and physical health approval and denial letters for Medicaid, Medicare, and the Exchange. In this role, you will use regulatory, accreditation, and departmental standards and apply medical health benefit policy and medical management guidelines to ensure letters provide the appropriate justification in authorizing services and appropriately deny services when guidelines are not met. The UM Correspondence RN will maintain current knowledge and understanding of the laws, regulations, DHS/NCQA requirements and policies that pertain to the organizational unit’s business and uses professional judgment in their application. This position will report noncompliance or other trends to leadership as appropriate.

Work Arrangement

• Remote role.
• Monday through Friday from 8:00a EST to 5:00p EST.
• Availability to work rotating weekends based on business needs is required.
• Must work 4 out of 10 holidays to include Thanksgiving and Christmas (rotating).

Responsibilities

• Navigates the documentation system (currently JIVA) and understands the utilization management review process for medical necessity determinations as well as the Medical Director rationale for determinations.
• Ensures that all languages meet the CFR (Code of Federal Regulations) requirements (i.e Flesh Kincaide level, grammar, readability and accurate dates).
• Ensures the translation process is followed if it is identified that the member’s language preference is one other than English.
• Collaborates with the Medical Directors in the event that rationale needs updated to meet all regulatory requirements.

Education and Experience

• Bachelor’s Degree required.
• Must be a Registered Nurse.
• Minimum of 3 years of diverse and independent clinical practice experience as a Registered Nurse.
• Minimum of 2 years of experience conducting inpatient, outpatient, and post acute utilization management reviews for a payor.
• Utilization management review experience in a managed care organization.
• Experience applying NCQA, individual state contract and CMS regulatory standards throughout the review process.
• Quality assurance or auditing experience in a managed care organization or acute care setting.

Licensure

• Active and unencumbered Enhanced Nurse Licensure Compact (eNLC) required.

Skills and Abilities

• Demonstrated ability to meet productivity measures in a high volume work environment.
• Strong analytical, data interpretation, and written and verbal communication skills.
• Decision making skills with ability to identify problems and recommend solutions.
• Detail oriented and process driven

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.