Utilization Management Reviewer

Amerihealth Caritas • ,

5d

About The Position

Utilization Management Reviewers evaluate the medical necessity and appropriateness of inpatient and outpatient services to ensure care aligns with clinical guidelines, regulatory requirements, medical policies, and patient needs. The reviewer evaluates provider requests, gathers and analyzes medical documentation, and independently applies medical and behavioral health criteria to make evidence-based determinations. The role also identifies care coordination opportunities and escalates cases to the Medical Director when further review is needed.

The position requires a strong working knowledge of federal, state, and organizational regulations, including Medicaid and Medicare standards. Reviewers are expected to meet turnaround times, quality benchmarks, and efficiency metrics in a fast-paced, high-volume environment. The stated schedule is Monday through Friday, 8:00 AM to 5:00 PM, with rotating work on some company holidays, including Thanksgiving and Christmas, and weekends based on business needs.

Requirements

• Associate’s Degree in Nursing (ASN).
• At least 3 years of diverse clinical experience as a Registered Nurse in an ICU, ED, Med-Surg, SNF, rehabilitation or LTAC, home health care, or medical office setting.
• At least 2 years of experience applying evidence-based criteria, such as InterQual, to complete prior authorization and concurrent reviews for inpatient and/or outpatient services.
• Active and unencumbered Registered Nurse license.
• Proficiency using Electronic Medical Record systems to 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.
• Ability to meet productivity standards in a fast-paced, high-volume utilization review environment.
• Proficiency with MS Office, including Excel, Word, Outlook, and Teams.
• Ability to type with speed and accuracy.

Nice To Haves

• Bachelor’s Degree in Nursing (BSN).
• Experience conducting utilization management reviews for a payor, such as Medicaid, Medicare, or a commercial plan.
• Active and unencumbered Nurse Licensure Compact (NLC).
• Ability to obtain additional RN licensure across the enterprise, including the District of Columbia, for select teams.

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 with 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.
• Meet established productivity metrics, turnaround times, efficiency expectations, and quality standards in a high-volume environment.

Benefits

• Flexible work solutions, including remote options and hybrid work schedules.
• Competitive pay.
• Paid time off.
• Paid holidays.
• Volunteer events.
• Health insurance coverage for the associate and dependents beginning on Day 1.
• 401(k).
• Tuition reimbursement.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree