Job Description

**Role Overview:** Under the direction of the supervisor, the Utilization Management Review Nurse is responsible for completing medical necessity reviews.; Using clinical knowledge and experience, the Utilization Management Review Nurse reviews the 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 Utilization Management Review Nurse's discretion to pend requests for additional information and/or request clarification. The Utilization Management Review Nurse will use their professional judgment to evaluate the request and ensure that services are appropriately approved, recognize care coordination opportunities and refer those cases to Population Health as needed.;; The Utilization Management Review Nurse will apply independent medical judgment to medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated. Utilization Management Review Nurse will ensure that treatment delivered is appropriate and meets the Member's needs in the least restrictive, least intrusive manner possible. The Utilization Management Review Nurse will maintain current knowledge and understanding of and regularly apply the laws, regulations, and policies that pertain to the organizational business units and uses clinical judgment in their application **Work Arrangement:** + Remote role + Monday through Friday from 8:00 AM to 5:00 PM or from 8:30 AM to 5:00 PM EST + Potential for weekends + Rotating holidays ; **Responsibilities:** + Conducts utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines. + Collaborates with healthcare providers to facilitate timely authorizations and optimize patient care. + Analyzes medical records and clinical data to ensure compliance with regulatory and payer guidelines. + Communicates determinations effectively, providing clear, evidence-based rationales for approval or denial decisions. + Identifies and escalates complex cases requiring physician review or additional intervention. + Ensures compliance with Medicaid industry standards. + Maintains productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment.; ; **Education & Experience:** + Associate Degree in Nursing (ASN) required; Bachelor Degree in Nursing (BSN) preferred. + An active and unencumbered compact state Registered Nurse (RN) license or Pennsylvania Registered Nurse license is required. + 3+ years of diverse clinical experience as a Registered Nurse to include Intensive Care Unit (ICU), Emergency Department (ED), Skilled Nursing Facility (SNF), ;Long-Term Acute Care (LTAC). + Proficiency in Electronic Medical Record (EMR) to efficiently document and assess patient cases. + 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. + Valid Driver's License and reliable automobile transportation for on-site assignments and off-site work-related activities. + Experience working in a remote role desired. ; Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. We want to connect with you if you're going to make a difference. Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at **Our Comprehensive Benefits Package** Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more. As a company, we support internal diversity through: Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.

Job Tags

Flexible hours, Weekend work, Monday to Friday,

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