Role Overview: Under the supervision of the manager, the Utilization Management Review Nurse is responsible for conducting medical necessity reviews. Using clinical expertise, the nurse reviews provider requests for inpatient and outpatient services, collaborating with members and providers to gather all necessary information for a thorough review. The nurse may request additional information or clarification as needed. The nurse applies professional judgment to evaluate requests, ensuring appropriate service approval, identifying care coordination opportunities, and referring cases to Population Health when necessary. They utilize independent medical judgment to interpret medical health benefit policies and guidelines to authorize services and escalate cases to the Medical Director when appropriate. The nurse ensures that treatment is appropriate, meets the member’s needs, and is delivered in the least restrictive manner. They stay current with laws, regulations, and policies relevant to their role and apply clinical judgment accordingly. Work Arrangement: Remote position Monday to Friday, 8:00 AM - 5:00 PM or 8:30 AM - 5:00 PM EST Potential weekend work Rotating holidays Responsibilities: Perform utilization management reviews assessing medical necessity and care appropriateness. Work with healthcare providers to facilitate timely authorizations and improve patient care. Review medical records and clinical data for compliance with guidelines and regulations. Communicate determinations clearly, providing evidence-based reasons for approvals or denials. Escalate complex cases requiring physician review or additional intervention. Ensure compliance with Medicaid standards. Maintain productivity and quality standards in a high-volume environment. Education & Experience: Associate Degree in Nursing (ASN) required; Bachelor’s in Nursing (BSN) preferred. At least 3 years of diverse clinical experience as a Registered Nurse, including ICU, ED, SNF, or LTAC. Proficiency with Electronic Medical Records (EMR). Strong knowledge of utilization review processes, medical necessity criteria, and regulatory compliance. Ability to meet productivity standards in a fast-paced environment. Valid Driver’s License and reliable transportation for on-site activities. Remote work experience is a plus. Licensure: Active, unencumbered RN license in a compact state or Pennsylvania. Join us and start your healthcare leadership journey. At AmeriHealth Caritas, we are dedicated to helping people access care, stay healthy, and build strong communities. As a national leader in healthcare solutions, we offer our team members opportunities to make a meaningful impact. Headquartered in Newtown Square, PA, we bring over 30 years of experience delivering comprehensive, outcomes-driven care, including managed care, pharmacy services, behavioral health, and administrative support. Learn more at Benefits: Flexible work arrangements including remote options, competitive pay, paid time off, holidays, volunteer events, health insurance from Day 1, 401(k), tuition reimbursement, and more. #J-18808-Ljbffr AmeriHealth Caritas
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