Utilization Management Review Nurse

AmeriHealth Caritas; Dover (DE); Hybrid; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a Clinical Care Reviewer – Utilization Management to enhance patient care and ensure compliance with medical guidelines. This role involves evaluating medical necessity for services, collaborating with healthcare providers, and maintaining productivity in a fast-paced environment. Ideal candidates will have a strong clinical background, a commitment to quality care, and the ability to navigate complex regulatory frameworks. Join a mission-driven organization dedicated to building healthier communities and making a meaningful impact in healthcare.

Benefits

Flexible work solutions

Competitive pay

Paid time off

Health insurance on Day 1

401(k) tuition reimbursement

Qualifications

• 3+ years of diverse clinical experience in various healthcare settings.
• Active RN license required; ASN preferred, BSN is a plus.

Responsibilities

• Evaluate medical necessity for inpatient and outpatient services.
• Collaborate with healthcare providers for timely authorizations.
• Analyze medical records to ensure compliance with guidelines.

Skills

Clinical Judgment

Utilization Review

Regulatory Compliance

Electronic Medical Record Systems

Patient Care Coordination

Education

Associate’s Degree in Nursing (ASN)

Bachelor’s Degree in Nursing (BSN)

Tools

Electronic Medical Record Systems

Job description

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 healthcare 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. We want to connect with you if you're going to make a difference. Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with over 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:

Under 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. ;The Clinical Care Reviewer – Utilization Management will also be counted upon to:

• Conduct concurrent 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.
• An active OH or compact state Registered Nurse (RN) license in good standing is required.
• 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.
• Availability to work Monday through Friday, 8:00 AM EST to 5:00 PM EST, flexible for holidays, occasional overtime, and weekends based on business needs.
• Current driver's license 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 implement these principles daily 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

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.