Behavioral Health Utilization Management Review

About the Role

Under the direction of the Supervisor, the Behavioral Health Utilization Management (BHUM) Reviewer completes 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. The BHUM Reviewer may retain requests for additional information and/or request clarification, applying professional judgment to evaluate requests, ensure appropriate services are approved, and recognize care coordination opportunities. Cases needing integrated care management are referred as needed. The BHUM Reviewer applies medical health benefit policy and medical management guidelines to authorize services and appropriately identifies and refers requests to the Medical Director when indicated.

The BHUM Reviewer ensures treatment delivered is appropriately utilized and meets the member’s needs in the least restrictive, least intrusive manner possible. They maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and use clinical judgment in their application.

Schedule

This is a remote role with the following schedule requirements:

• Monday through Friday from 8:00 AM EST to 5:00 PM EST
• Must work 4 out of 10 recognized company holidays, including Thanksgiving and Christmas (rotating schedule)
• Must be willing to work 2 to 3 weekends per year, based on business needs

Requirements

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, or co-occurring disorders in a partial hospitalization program (PHP), intensive outpatient program (IOP), and/or residential treatment program
• Utilization management experience in a managed care organization preferred
• Experience working in a remote work environment preferred

Licensure

• For LSW: Active and unencumbered professional licensure/independent licensure in Ohio: LPC, LCSW, LICSW, LISW, LCMHC, or LMFT
• Must have the ability to obtain additional licensure in LA, NC, NH, and DC within 12 months from date of hire
• For RN: Active and unencumbered RN license in Ohio and/or a compact state nurse license
• Must have the ability to obtain additional licensure in LA, NC, NH, and DC within 12 months from date of hire

Skills & Abilities

• Proficiency in Microsoft Office, including Word, Excel, Teams, and Outlook
• Consistent and accurate typing skills
• Ability to communicate in a positive and professional manner, both orally and in writing
• Strong problem-solving 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 and complete tasks within the allotted time frame

Benefits

AmeriHealth Caritas offers a comprehensive benefits package, including:

• Flexible work solutions, including remote and hybrid work schedules
• Competitive pay
• Paid time off, including holidays and volunteer events
• Health insurance coverage for you and your dependents, effective on Day 1
• 401(k) retirement plan
• Tuition reimbursement

AmeriHealth Caritas is a mission-driven organization with over 30 years of experience delivering comprehensive, outcomes-driven care. Headquartered in Newtown Square, the company offers integrated managed care products, pharmaceutical benefit management, specialty pharmacy services, behavioral health services, and other administrative services.