Role Overview:

Under the direction of the Manager, Behavioral Health Utilization Review , the Behavior Health Utilization Management Reviewer (BHR) is responsible for completing medical necessity reviews.   Using clinical knowledge and experience, the clinician reviews 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.

Work Arrangement: 

• Remote role.
• Monday through Friday from 8:00a ET to 5:00p ET.

Responsibilities: 

• Ensures that appropriate services are approved and recognize care coordination opportunities and refer those cases to integrated care management as needed.  
• Applies medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated.
• Ensures that treatment delivered is appropriately utilized and meets the Member’s needs in the least restrictive, least intrusive manner possible.
• Maintains current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.

Education and Experience:

• Registered Nurses must have an Associate Degree in Nursing. Bachelor Degree preferred.
• Licensed Social Workers must have a Master Degree in Social Work.
• Minimum of 2 years of behavioral health and substance use disorder experience. 
• Utilization management experience in a managed care organization preferred.
• Proficiency in Microsoft Office, including Word, Excel and Outlook is required. Consistent word processing speed and accuracy of 50 or more words per minute.
• Experience working in a remote work environment preferred.
• Ability to communicate in a positive/professional manner both orally and written.
• Ability to follow detailed instructions with a high degree of accuracy.
• Ability to work independently; complete tasks in the allotted time frame.
• Strong problem-solving skills and decision making skills.
• Strong organizational and time management skills.

Licensure: 

• Current and unrestricted Registered Nurse license and/or compact state license.

• Current and unrestricted independent Social Work licensure to include LPC, LCSW, LISW, LMHC, LCHMC.

• Must obtain licensure in DC, NH, NC and LA within 12 months from date of hire. 

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.

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.