Clinical Care Reviewer – Utilization Management, Registered Nurse, Licensed Clinical Social Wor[...]

AmeriHealth Caritas; Philadelphia (Philadelphia County); On-site; USD 70,000 - 90,000; Full time

Job summary

AmeriHealth Caritas seeks Clinical Care Reviewers in various specialties for remote roles that prioritize clinical judgment and collaboration. As a leader in health care solutions, we invite passionate professionals to join our mission-driven team, reviewing service requests and driving better health outcomes for our communities.

Benefits

100% remote flexibility

Diverse opportunities under one application

Supportive team environment

Qualifications

• 3+ years of clinical experience in relevant settings.
• Previous Utilization Management or managed care experience preferred.
• Strong proficiency in remote collaboration and documentation.

Responsibilities

• Review service requests for medical necessity using InterQual standards.
• Collaborate with families and providers to coordinate care.
• Document findings in EMR systems and meet performance metrics.

Skills

Analytical skills

Communication skills

Time-management skills

Education

Registered Nurse (RN) License

Behavioral Health License (LCSW, LPC, etc.)

Tools

EMR systems (e.g., JIVA, InterQual)

Job description

Multiple Opportunities | RN & Behavioral Health Licensure | Remote & Flexible Schedules

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. Discover more about us at www.amerihealthcaritas.com .

Join a mission-driven Utilization Management team where your clinical expertise helps shape better outcomes. We're hiring Clinical Care Reviewers across multiple specialties—medical and behavioral health—for roles that balance autonomy, clinical judgment, and meaningful collaboration. Lead with Clinical Insight. Whether you’re an experienced utilization review nurse, a sharp case manager, or a behavioral health clinician ready to make an impact behind the scenes, this is your moment. As a Clinical Care Reviewer, you'll evaluate inpatient, outpatient, pediatric, or behavioral health services to ensure they align with clinical guidelines and regulatory standards. You’ll apply your expertise to complex cases, collaborate with providers, and drive timely, well-informed care decisions that make a real difference. This isn’t floor work—it’s clinical leadership with purpose.

What You’ll Do:

• Review inpatient, outpatient, and behavioral health service requests for medical necessity using InterQual and regulatory standards.
• Partner with families, providers, and internal teams to coordinate timely, effective care.
• Document clearly and consistently in EMR systems and meet quality and productivity metrics.
• Escalate complex cases for Medical Director review as needed.

We’re Hiring for:

• General UM (RN): Mon–Fri, 8 AM–5:30 PM. Occasional evenings/weekends based on need.
• Pediatric Shift Care (RN): Mon–Fri, 8:30 AM–5 PM EST. Remote. Pediatric/home health experience preferred.
• Evening/Weekend UM (RN): Mon–Fri, 5 PM–12 AM + rotating Sat/Sun. Remote. Medicaid experience preferred.

• Behavioral Health UM (LPC, LCSW, LMHC, etc.): Mon–Fri, EST hours with limited holidays/weekends.

What You Bring:

• RN or independent BH license (LCSW, LPC, etc.) in good standing; compact licensure for RNs strongly preferred.
• 3+ years of clinical experience in ICU, ED, Med-Surg, pediatrics, behavioral health, or similar.
• Prior Utilization Management or managed care experience preferred.
• Strong analytical, communication, and time-management skills.
• EMR proficiency (e.g., JIVA, InterQual).

Why Us:

• 100% remote flexibility for most roles.
• Diverse opportunities under one streamlined application.
• Fast-paced, impactful work with a supportive team
• Real potential to grow and make a difference

Apply today to explore the opportunity that best fits your expertise—one application opens the door to multiple roles