Behavioral Health Utilization Management Reviewer

Amerihealth Caritas•Washington, DC

3d•$77,700 - $105,900•Hybrid

About The Position

Under the direction of the Supervisor, the Behavioral Health Utilization Management (BHUM) 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 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.

Requirements

Registered Nurse candidates: Associate Degree in Nursing required.
Licensed Social Worker candidates: Master Degree in Social Work required.
Minimum of 2 years of independent clinical practice experience assessing and treating individuals with behavioral health/substance use/co-occurring disorders.
Proficiency in Microsoft Office, including Word, Excel, Teams, and Outlook.
Consistent and accurate typing skills.
Ability to communicate in a positive/professional manner both orally and written.
Strong problem-solving skills 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; complete tasks in the allotted time frame.
Active and unencumbered professional licensure/independent licensure in DC: LPC, LICSW, LCMHC, LMFT (for LSW candidates).
Active and unencumbered RN license in DC (for RN candidates).
Must have ability to obtain additional licensure in LA, NC, NH and OH within 12 months from date of hire (for LSW candidates).
Must have ability to obtain additional licensure in LA, NC, NH and DC within 12 months from date of hire (for RN candidates).
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.

Nice To Haves

Bachelor Degree in Nursing preferred (for RN candidates).
Utilization management experience in a managed care organization preferred.

Responsibilities

Completing medical necessity reviews for inpatient and outpatient services.
Collecting information from members and providers for thorough medical necessity reviews.
Retaining requests for additional information and/or requesting clarification.
Evaluating requests using professional judgment to ensure appropriate services are approved.
Recognizing care coordination opportunities and referring cases to integrated care management.
Applying medical health benefit policy and medical management guidelines to authorize services.
Identifying and referring requests to the Medical Director when indicated.
Ensuring treatment delivered is appropriately utilized and meets member needs in the least restrictive, least intrusive manner possible.
Maintaining current knowledge and understanding of laws, regulations, and policies pertaining to the business.
Using clinical judgment in the application of laws, regulations, and policies.