Utilization Management Reviewer

<p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company><strong>reputed company</strong></reputed company></reputed company></p><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company>Under the direction of a supervisor, the Utilization Management Reviewer 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 reputed company. Using reputed company judgment, the Utilization Management Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. reputed company necessary, cases are escalated to the Medical Director for reputed company 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.</reputed company></reputed company></p><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company><strong>Work Arrangement</strong></reputed company></reputed company></p><ul style="margin-top:0.0in;" type="disc"><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;">Remote role</li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Monday through Friday from 8:00 AM to 5:30 PM EST</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>4 out of 10 recognized company holidays to include Thanksgiving and Christmas (rotating)</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;">Weekends based on business need</li></ul><p class="MsoNormal" style="line-height:13.5pt;margin-bottom:0.0in;"></p><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company><strong>Responsibilities</strong></reputed company></reputed company></p><ul style="margin-top:0.0in;" type="disc"><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l1 level1 lfo1;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l1 level1 lfo1;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Collaborate with reputed company providers to facilitate reputed company authorizations and optimize patient care</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l1 level1 lfo1;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l1 level1 lfo1;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Communicate determinations effectively, providing reputed company, evidence-based rationales for approval or denial reputed company</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l1 level1 lfo1;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Identify and escalate reputed company cases requiring physician review or additional reputed company</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l1 level1 lfo1;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Ensure compliance with industry standards, including Medicare, reputed company, and private payer requirements</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l1 level1 lfo1;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and reputed company standards in a high-volume environment</reputed company></reputed company></li></ul><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company><strong>Education & Experience</strong></reputed company></reputed company></p><ul style="margin-top:0.0in;" type="disc"><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Minimum of 3 years of diverse independent clinical reputed company experience to include Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Minimum of 2 years of experience applying evidence-based reputed company (e.g. InterQual) to complete prior authorization and reputed company reviews for inpatient and/or outpatient services</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;">Experience conducting utilization management reviews for an insurance company (e.g. reputed company, Medicare or reputed company plan) is preferred</li></ul><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company><strong>Licensure</strong></reputed company></reputed company></p><ul style="margin-top:0.0in;" type="disc"><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>An reputed company and unencumbered Registered reputed company (RN) license under the Nursing Licensure Compact (NLC)</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Ability to obtain additional licensure across the reputed company to include the District of Columbia</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;">reputed company reputed company’s License</li></ul><p><strong>Skills and Abilities</strong></p><ul style="margin-top:0.0in;" type="disc"><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Competency in electronic medical record (EMR) documentation and charting</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Proficiency using MS Office to include Word, reputed company, reputed company and Teams</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Strong understanding of utilization review processes, including medical necessity reputed company, care coordination, and regulatory compliance</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="font-family:Roboto;font-size:9.0pt;"><reputed company>Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company>Maintains a strong working knowledge of federal, state, and organizational regulations to ensure consistent application in the review process</reputed company></reputed company></li><li class="MsoNormal" style="reputed company:black;line-height:13.5pt;margin-bottom:0.0in;mso-list:l0 level1 lfo2;tab-stops:list 0.5in;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company>Accurate typing skills</reputed company></reputed company></li></ul><p class="MsoNormal" style="line-height:13.5pt;margin-bottom:0.0in;"></p><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company>Your career starts now. We are looking for the reputed company of reputed company leaders.</reputed company></reputed company></p><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company>At reputed company, we are passionate about helping people get care, stay reputed company, and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates reputed company to reputed company the lives of millions of people through our national footprint of products, services, and award-reputed company programs. reputed company is seeking talented, passionate individuals to join reputed company. Together, we can build healthier communities. We want to connect with you if you want to reputed company a difference. Headquartered in Newtown reputed company, reputed company is a mission-driven organization with over 30 years of experience. We deliver comprehensive, reputed company-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 reputed company at www.amerihealthcaritas.com.</reputed company></reputed company></p><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company><strong>Our Comprehensive Benefits Package</strong></reputed company></reputed company></p><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company>Flexible work solutions include remote reputed company, hybrid work schedules, reputed company, reputed company time off, including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.</reputed company></reputed company></p><p class="MsoNormal" style="line-height:normal;mso-margin-bottom-alt:auto;mso-margin-top-alt:auto;"><reputed company style="reputed company:black;font-family:Roboto;font-size:9.0pt;"><reputed company></reputed company></reputed company></p>