After-Hours Behavioral Health Utilization Management Reviewer, RN/LMSW

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, Pennsylvania, ;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.

Responsibilities:

The After-Hours Behavioral Health (BH) Utilization Management (UM) Reviewer will be 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 pre-determined 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 BH UM Reviewer’s discretion to retain requests for additional information and/or request clarification when necessary.;

The BH UM Reviewer uses their professional knowledge and judgment along with standardized criteria to evaluate the request to ensure that appropriate services are approved, and they will use standardized operating procedures to 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. ;They are not permitted to deny a request for services; instead, they appropriately identify and refer requests to the Medical Director when required. The BH UM Reviewer 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. The BH UM Reviewer 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:

• Please note the hours for this position are 1:30pm-12am Tuesdays, Wednesdays, and Thursdays and 9:30am-8pm Saturdays.
• Requirements for RN:
• ;Associate Degree in Nursing and unencumbered RN license. BSN preferred.
• Minimum of 5 years of behavioral health and/or substance use disorder.;
• Requirements for LMSW:;
• Master’s Degree in Social Work and independently licensed in social work, marriage and family counseling, or professional counseling.
• Minimum of 3 years of experience in behavioral health and/or substance use disorder. ; ; ; ; ; ; ; ; ; ; ;
• Managed care and utilization management experience required.
  
  

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our comprehensive benefits package includes: 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.