Utilization Management Reviewer

Role Overview

Our Utilization Management Reviewers evaluate 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 Clinical Care 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. The Utilization Management Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making.

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 Medicaid and Medicare industry standards
• Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment

Requirements

• Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred
• Minimum of 3 years of diverse clinical experience as a Registered Nurse in an Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation or Long-Term Acute Care (LTAC), home health care, or medical office setting
• Minimum of 2 years of experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient and/or outpatient services
• Experience conducting utilization management reviews for a payor (e.g. Medicaid, Medicare or commercial plan) preferred

Education and Experience

Active and unencumbered Registered Nurse license required

Active and unencumbered Nurse Licensure Compact (NLC) preferred

Skills and Abilities

• Proficiency using Electronic Medical Record Systems to efficiently document and assess patient cases
• Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance
• Working knowledge of InterQual criteria
• Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment
• Proficiency using MS Office to include Excel, Word, Outlook, and Teams
• Ability to type with speed and accuracy

Benefits

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.

Comprehensive Benefits Package

• Flexible work solutions including remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k) tuition reimbursement