Utilization Management Reviewer

Amerihealth Caritas•Washington, DC

1d•Hybrid

About The Position

Under the direction of a supervisor, the Utilization Management Reviewer evaluates 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 Utilization Management 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. Work Arrangement Monday through Friday from 8:30 AM EST to 5:00 PM EST; 2 days must be worked in our DC office located at 1201 Maine Ave SW and 3 days can be worked remotely Must work 4 recognized company holidays to include Thanksgiving and Christmas (rotating) Weekends and overtime based on business need

Requirements

Associate’s Degree in Nursing (ASN) required
Minimum of 3 years of diverse independent clinical practice experience as a Registered Nurse in outpatient surgery, Medical-Surgical, Critical Care, Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings
Experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient, outpatient and/or post acute services
Experience conducting utilization management reviews specific to a Medicare population across multiple states for a payer preferred
An active and unencumbered Registered Nurse (RN) license in the District of Columbia required
Competency in electronic health record (EHR) documentation and charting
Proficiency using MS Office to include Word, Excel, Outlook and Teams
Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance
Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment
Maintains a strong working knowledge of federal, state, and organizational regulations to ensure consistent application in the review process
Ability to type with accuracy and speed
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’s Degree in Nursing (BSN) preferred

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