Role Overview:

Under the direction of the Supervisor, the Behavioral Health Utilization Management (BHUM) Reviewer 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. It is within the BH UM Reviewer’s discretion to retain requests for additional information and/or request clarification. The BH UM Reviewer will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases to integrated care management as needed. The BH UM Reviewer will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated. The BH UM Reviewers are responsible to ensure that treatment delivered is appropriately utilized and meets the member’s needs in the least restrictive, least intrusive manner possible. The BH UM Reviewer will maintain 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.

Responsibilities:

• Applies the appropriate medical necessity criteria to authorize services and appropriately identify and refer requests to the Medical Director when indicated. 

• Ensures the 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.

  
   

Work Arrangement:

• Remote position 
• Monday through Friday 8:00 AM to 5:00 PM during Central Standard Time.
•  Candidates must be willing to work 4 out of 10 recognized company holidays and 1 to 2 weekends per year.

Education & Experience:

• Associate Degree in Nursing (required) or Bachelor Degree in Nursing (preferred) OR Master’s Degree and independently licensed in social work, marriage and family counseling or professional counseling required.
• Minimum of 2 years of behavioral health experience and substance use disorder experience in a clinical setting.
• Proficiency using InterQual and American Society of Addiction Medicine (ASAM) criterion.
• Utilization management experience within a managed care organization desired.
• Proficiency in Microsoft Office to include Teams, Word, Excel and Outlook is required. Ability to type with speed and accuracy.

Licensure:

• Current and unencumbered professional licensure required:  LPC, LMSW, LCSW, LISW in Louisiana OR Registered Nurse with compact state license or Louisiana state license. 

• Ability to obtain additional licensure as needed.

Your career starts now. We’re looking for the next generation of healthcare 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 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. 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.

#PH