Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care 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. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 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.

Work Arrangement 

   ·  This is a remote position. 

Job Summary

Reporting to the Corporate Director Utilization Management Operations, this position is representing Behavioral Health UM in plan/state interactions/audits, validation of regulatory reporting/analytics for UM, and serves as SME for clinical components of the Medicaid Utilization Management Program.  Works in close collaboration with all departments to achieve regulatory standards and optimal departmental outcomes. Develops solutions that may consist of process improvements and/or system development components and are intended to optimize the functionality of the applications and related processes to support the business’ needs.  Analyzes the needs of the organization with the commitment to design and implement solutions that best support the needs of the business.  This position will solicit ideas for systems improvements, review and present new system enhancements/features, and engage in continuous improvement planning, including testing and roll-out of UM changes. 

Responsibilities:

• Have working knowledge of prior authorization, medical necessity determinations, concurrent review, retrospective review, continuity of care, care coordination, and other clinical and medical management programs.
• Have a working knowledge of Mental Health Parity requirements.
• Have a working knowledge of internal and external audit functions (including but not limited to NCQA, EQRO, IPRO, CMS Audits, etc.).
• Have working knowledge of all applicable statutory provisions, contracts and established policies and administrative procedures.
• Serve as designee for plan specific Quality Meetings, corporate UM meetings, plan UM meetings, state UM meetings and functions.
• Assist in preparation, coordination, and participation in and follow up of Utilization Management audits, such as readiness review, Data Validation, CMS Program Audit and Compliance/Internal audits, pertaining to the OH Utilization Management program.
• Assist in the development of mitigation or remediation processes from any deficiencies in scheduled Performances Reviews, CMS audits, EQRO audits. Establish action plan for assessment and resolution of identified issues.
• Participate in current process review and development of new and / or revised work processes, policies and procedures relating to Behavioral Health Utilization Management responsibilities. Develop educational material and programs necessary to meet business objectives, members’ needs, OH contractual and regulatory guidelines and staff professional development.
• Comply with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information.

Education/Experience:

• Master’s Degree with independent licensure in social work, marriage and family therapy, professional counseling and/or addictions.
• Current unrestricted RN Licensure with Psychiatric Nursing Certification can be in lieu of master’s degree requirement.
• Demonstrated ability to assess department’s work quality and develop/implement process improvements to achieve contractual and oversight compliance.
• Experience in managing multiple processes and being and influencer.
•  Demonstrated competency in use of healthcare data.
•  Maintain a current knowledge of company policy and procedures Medicaid Medical Necessity guidelines and InterQual criteria access and delivery of services.
•  Maintain understanding of managed care and impact on services including but not limited to, prior authorization, inpatient review, discharge planning, home health, and SNF/Rehabilitation Services.
• 3 years utilization / case management experience in relevant scope preferred, one year required.
• 3 to 5 years relevant clinical practice required/three years Utilization management.           

Other Skills:

• Strong organizational and prioritization skills.
• Excellent analytical and problem-solving skills.
• Strong computer skills.
• Proficiency and speed working in all Microsoft office Suite applications.
• Understanding of and expertise in quality and process improvement.
• Excellent/professional communication skills.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.