After Hours Utilization Management Review Nurse

Role OverviewUnder the direction of a supervisor, the Clinical Care Reviewer Utilization Management (UM) will be scheduled to work non-traditional hours to provide access to medical necessity determinations for urgent requests 24/7, 365 days a year. The Clinical Care Reviewer UM evaluates medical necessity for inpatient 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 UM 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 UM 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. Work ArrangementQualified candidates must be available to work a schedule of 5 days/40 hours week consisting of M-F from 5p to 12a and any shift on Saturday and SundayRemoteResponsibilitiesConduct concurrent reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelinesCollaborate with healthcare providers to facilitate timely authorizations and optimize patient careAnalyze medical records and clinical data to ensure compliance with regulatory and payer guidelinesCommunicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisionsIdentify and escalate complex cases requiring physician review or additional interventionEnsure compliance with Medicaid industry standardsMaintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environmentEducation and ExperienceAssociate's Degree in Nursing (ASN) required; Bachelor's Degree in Nursing (BSN) preferred3 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 settingLicensureAn active and unencumbered Registered Nurse (RN) license in good standing is requiredSkills & AbilitiesProficiency in Electronic Medical Record Systems to efficiently document and assess patient casesStrong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory complianceDemonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environmentYour career starts now. We are looking for the next generation of healthcare leadersAt AmeriHealth Caritas, we are 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 would like to connect with you.Headquartered in Newtown Square, Pennsylvania, 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.Our comprehensive benefits package includes: flexible work solutions including remote options, hybrid work schedules, competitive pay, paid time off including holidays and participation in volunteer events, health insurance coverage for you and your dependents begins day 1 of employment, 401(k), tuition reimbursement, and more.