Behavioral Health Utilization Management Reviewer, RN/LMSW

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re 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. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, Pennsylvania, 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.

Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

Under the direction of the Supervisor, the Behavioral Health Utilization Management Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and experience, the clinician reviews 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. The BH UM Reviewer will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and 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 and appropriately identify and refer requests to the Medical Director when indicated. The BH UM Reviewers are responsible to ensure that treatment delivered is appropriately utilized and meets the member’s needs in the least restrictive, least intrusive manner possible. The BH UM Reviewer will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.

Education/Experience:

• While this is a remote role, qualified candidates will reside in Eastern Standard Time or Central Standard Time.
• Must be able to work Monday through Friday from 8:30a to 5:00p EST, 4 out of 10 recognized company holidays, and 1 rotating weekend per year (based on business needs).
• RN Requirements: Associate Degree in Nursing. Bachelor Degree preferred. Current and unrestricted RN license.
• LMSW Requirements: Master's Degree and current and unrestricted licensure in social work to include LPC, LMHC, LICSW.
• Must have ability to obtain additional licensure in OH, LA, NC, and DC.
• Minimum of 2 years of behavioral health and substance use disorder experience.
• Utilization management experience in a managed care organization preferred.
• Proficiency in Microsoft Office, including Word, Excel and Outlook is required. Consistent word processing speed and accuracy of 50 or more words per minute.
• Experience working in a remote work environment preferred.
• Ability to communicate in a positive/professional manner both orally and written.
• Ability to follow detailed instructions with a high degree of accuracy.
• Ability to work independently; complete tasks in the allotted time frame.
• Strong problem-solving skills and decision making skills.
• Strong organizational and time management skills.

Diversity, Equity, and Inclusion

At Amerihealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

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.