After Hours Utilization Management Reviewer

Role Overview:

The After Hours Utilization Management Reviewer is scheduled to work non-traditional hours to provide access to medical necessity determinations for urgent or required coverage requests on a 24/7, 365 basis. This position is required to cover nights, weekends and holidays.

Under the direction of a supervisor, you will 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 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:

• Remote role
• Work schedule is between the hours of 5:00 PM to 8:00 AM Monday through Friday
• Rotating weekends (both Saturday and Sunday) between the hours of 8:00 AM to 8:00 PM and 8:00 PM to 8:00 AM
• 4 out of 10 company recognized holidays to include Thanksgiving and Christmas (rotating)

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 industry standards.

• Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment.

Education and Experience:

• Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred
• Minimum of 3 years of diverse and independent clinical practice experience
• Minimum of 2 years of current experience performing prior authorization and concurrent reviews for in and outpatient services using evidence-based criteria

• Must have utilization management review experience in a managed care organization

Licensure:

• Current and unencumbered Nurse Licensure Compact (NLC)
• Current driver's license

• Must be able to obtain licensure in all markets across the enterprise to include the District of Columbia

Skills and Abilities

• Proficiency using Electronic Medical Record Systems to efficiently document and assess patient cases

• 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 pivot between high priority tasks to meet productivity standards in a fast-paced, high-volume utilization review environment
• Ability to gather and critically evaluate clinical information and criterion

• Accurate typing skills

• Maintains a strong working knowledge of federal, state, and organizational regulations and consistent application in review process

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 www.amerihealthcaritas.com.

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.