Utilization Management Review Nurse
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Role OverviewUnder the direction of a supervisor, the Clinical Care Reviewer – Utilization Management evaluates 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 Clinical Care 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. The Clinical Care Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making. Productivity expectations include meeting established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment.

$5,000.00 SIGN ON BONUSRole OverviewUnder the direction of a supervisor, the Clinical Care Reviewer – Utilization Management evaluates 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 Clinical Care 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. The Clinical Care Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making. Productivity expectations include meeting established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment.Work Arrangement

• Candidates are required to work 4 out of 5 days a week at our AmeriHealth Caritas DC office located at 1201 Maine Avenue, S.W., Suite 1000, 10th Floor, Washington DC 20024
• Availability to work Monday through Friday, 8:00 AM to 5:00 PM, flexible for evenings, holidays, occasional overtime, and weekends based on business needs

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 & Experience

• Associate's Degree in Nursing (ASN) required; Bachelor's Degree in Nursing (BSN) preferred
• Minimum of 3 years of diverse clinical experience in an Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC), home health care, or medical office setting
• Proficiency in Electronic Medical Record Systems to efficiently document and assess patient cases.
• Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance.
• Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment.
• Current driver's license required

Licensure

• An active and unencumbered Registered Nurse license in the District of Columbia is required.

The range displayed in this job posting reflects the minimum and maximum for new hire salaries for the position in the Washington DC area.Within the range, individual pay is determined by additional factors, including, without limitation, job-related skills, experience, and relevant education, certifications, or training.AmeriHealth Caritas associates are eligible to participate in our annual incentive program and will also receive our benefits package, consisting of medical, vision, dental, life insurance, disability insurance, 401(k), paid time off and more. The targeted hiring range for this role is expected to be between $84,400.00 or $40.10/hour and $113,600.00 or $54.62/hour.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 PackageFlexible 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.#PH

Seniority level

• Seniority levelMid-Senior level

Employment type

• Employment typeFull-time

Job function

• Job functionHealth Care Provider
• IndustriesHospitals and Health Care

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