Utilization Management Reviewer

Amerihealth Caritas•,

1d•Hybrid

About The Position

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. Productivity expectations include meeting established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment.

Requirements

Associate’s Degree in Nursing (ASN) required
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
Active and unencumbered Registered Nurse license required
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

Nice To Haves

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

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