After Hours Behavioral Health Clinical Care Utilization Management Reviewer

Amerihealth Caritas•,

6d•Remote

About The Position

The After-Hours Behavioral Health Utilization Management Reviewer works non-traditional hours to provide access to medical necessity determinations for urgent and contractually required coverage requests 24 hours a day, 365 days a year. Under the direction of the Supervisor, the reviewer assists members with specialized behavioral health care coordination and care management by conducting medical necessity reviews using standard operating procedures and predetermined criteria. The reviewer evaluates provider requests for inpatient and outpatient services, works with members and providers to obtain information needed for thorough reviews, and may retain requests for additional information or seek clarification. Using clinical judgment and standardized criteria, the reviewer evaluates requests, applies medical health benefit policy and medical management guidelines to authorize services, and identifies cases for referral to integrated care management. Reviewers do not deny service requests; they refer requests to the Medical Director when required. The role ensures care is appropriate and meets members’ needs in the least restrictive and least intrusive manner while meeting contractual turnaround times and maintaining current knowledge of applicable laws, regulations, and policies. This is a remote role scheduled between 12:00 AM and 8:00 AM EST, Tuesday through Sunday or Wednesday through Sunday. The associate must work four of ten recognized company holidays, including Thanksgiving and Christmas, on a rotating basis. Remote associates need reliable high-speed internet with minimum speeds of 50 Mbps download and 5 Mbps upload.

Requirements

Registered Nurse candidates must have an Associate Degree in Nursing.
Licensed Social Worker candidates must have a Master Degree in Social Work.
At least 2 years of independent clinical practice assessing and treating individuals with mental health, substance use, or co-occurring disorders in a PHP, IOP, and/or residential treatment program.
At least 3 years of utilization management experience for a payor (Medicaid or Medicare).
Experience working in a remote work environment.
LSW candidates must hold an active, unencumbered professional/independent license such as LPC, LCSW, LICSW, LISW, LCMHC, or LMFT.
RN candidates must hold an active, unencumbered RN license.
Ability to obtain additional licensure in OH, LA, NC, NH, and DC within 12 months of hire.
Proficiency in Microsoft Office, including Word, Excel, Teams, and Outlook.
Experience using Electronic Health Records.
Consistent and accurate typing skills.
Ability to communicate positively and professionally, both orally and in writing.
Strong problem-solving and decision-making skills.
Strong organizational and time-management skills.
Ability to follow detailed instructions accurately.
Ability to work independently and complete tasks within allotted time frames.
Must work four of ten recognized company holidays, including Thanksgiving and Christmas, on a rotating basis.
For remote work, access to reliable high-speed internet with at least 50 Mbps download and 5 Mbps upload.

Nice To Haves

Bachelor Degree in Nursing for Registered Nurse candidates.

Responsibilities

Provide medical necessity determinations for urgent and contractually required coverage requests during after-hours coverage.
Assist members with specialized behavioral health care coordination and care management services.
Review provider requests for inpatient and outpatient services using standard operating procedures and predetermined criteria.
Work with members and providers to collect information needed to conduct thorough medical necessity reviews.
Retain requests for additional information or seek clarification when necessary.
Apply clinical knowledge, standardized criteria, medical health benefit policy, and medical management guidelines to evaluate and authorize services.
Identify care coordination opportunities and refer cases to integrated care management as needed.
Refer service requests to the Medical Director when required; reviewers are not permitted to deny requests.
Ensure treatment is appropriate and meets members’ needs in the least restrictive and least intrusive manner possible.
Meet contractual turnaround times and maintain current knowledge of applicable laws, regulations, and policies.