Behavioral Health Utilization Management Reviewer

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.

Work Arrangement

• Remote role

• Monday through Friday from 8:00 AM EST to 5:00 PM EST

• Candidates must be willing to work 1 to 2 weekends per year. Weekend rotation based on business needs

• Must be able to work 4 out of 10 calendar holidays per year to include Thanksgiving and Christmas (rotating)

Education & Experience

• Registered Nurse candidates: Associate Degree in Nursing required; Bachelor Degree in Nursing preferred

• Licensed Social Worker candidates: Master Degree in Social Work required

• Minimum of 2 years of independent clinical practice experience assessing and treating individuals with behavioral health and substance use disorders in a clinical setting

• Direct patient care experience in an Intensive Outpatient Program (IOP) and/or Partial Hospitalization Program (PHP) desired

• Experience with Community Psychiatric Support and Treatment (CPST) and/or Psychosocial Rehabilitation Services (PSR) desired

• Utilization management experience in a managed care organization preferred

• Experience working in a remote work environment preferred

Licensure

• Requirements for LSW: Active and unencumbered professional licensure/independent licensure in Louisiana required: LPC, LCSW, LICSW, LISW, LCMHC, LMFT

• Must have ability to obtain additional licensure in OH, NC, NH and DC within 12 months from date of hire

• Requirements for RN: Active and unencumbered RN license in Louisiana and/or compact state nurse license required

• Must have ability to obtain additional licensure in OH, NC, NH and DC within 12 months from date of hire

Skills & Abilities

• Proficiency in Microsoft Office, including Word, Excel, Teams, and Outlook

• Consistent and accurate typing skills

• Ability to communicate in a positive/professional manner both orally and written

• Strong problem-solving skills and decision making skills

• Strong organizational and time management skills

• Ability to follow detailed instructions with a high degree of accuracy

• Ability to work independently; complete tasks in the allotted time frame

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

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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.

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.