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AmeriHealth Caritas
Utilization Management ReviewerAmeriHealth Caritas • Washington, DC
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Utilization Management Reviewer

Utilization Management Reviewer

AmeriHealth Caritas • Washington, DC
30+ days ago
Job type
  • Full-time
Job description

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 and Experience

  • Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred
  • Minimum of 3 years of diverse clinical experience as a Registered Nurse 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
  • Minimum of 2 years of experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient and/or outpatient services
  • Experience conducting utilization management reviews for a payor (e.g. Medicaid, Medicare or commercial plan) preferred

Licensure

  • Active and unencumbered Registered Nurse license in the District of Columbia

Skills and Abilities

  • Proficiency using 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
  • Working knowledge of InterQual criteria
  • Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment
  • Proficiency using MS Office to include Excel, Word, Outlook, and Teams
  • Ability to type with speed and accuracy

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 .

Our Comprehensive Benefits Package

Flexible 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.

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Utilization Management Reviewer • Washington, DC

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