Role Overview:

The After Hours Behavioral Health (BH) Utilization Management (UM) Reviewer is scheduled to work non-traditional hours to provide access to medical necessity determinations for urgent and contractually required coverage requests 24/7, 365 days a year.       

Under the direction of the Supervisor, the After Hours BH UM Reviewer is responsible for assisting members with appropriate specialized behavioral health care coordination and care management services by completing medical necessity reviews through the application of standard operating procedures and predetermined criteria.  Using clinical knowledge and experience, the BH UM Reviewer 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 the Reviewer’s discretion to retain requests for additional information and/or request clarification when necessary. 

Work Arrangement:

• Remote role.

• Saturday through Wednesday from 4:00p EST to 12:30a EST.

   

Responsibilities:

• Uses professional knowledge and judgment along with standardized criteria to evaluate the request to ensure that appropriate services are approved.

• Uses standardized operating procedures to 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.

• Appropriately identifies and refers requests to the Medical Director when required.

• Ensures the treatment delivered is appropriate and meets the Member’s needs in the least restrictive, least intrusive manner possible while adhering to tight contractual turnaround times.

• Maintains current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational business units and uses clinical judgment in their application.

Education/Experience:

• Registered Nurse candidates must have an Associate Degree in Nursing. Bachelor Degree in Nursing preferred.
• Licensed Social Work candidates must have a Master Degree in Social Work. 
• Registered Nurse candidates must have a minimum of 5 years of clinical practice experience in behavioral health and/or substance use disorder.
• Licensed Master Social Worker candidates must have a minimum of 3 years of clinical practice experience in behavioral health and/or substance use disorder.                        
• Managed care and utilization management experience required.

Licensure: 

• RN candidates must have an active and unencumbered license. 
• LMSW candidates must be  independently licensed in social work, marriage and family counseling, or professional counseling.

• Additional licensure  in DC, NH, OH, NC, and LA will be required..

   

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 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 would like to connect with 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 participation in volunteer events, health insurance coverage for you and your dependents begins day 1 of employment, 401(k),  tuition reimbursement, and more.