AmeriHealth Caritas

Title: Behavioral Health Utilization Management Reviewer Location Remote, United States Primary Job Function Behavioral Health ID 44620 Job Description: Role Overview Under the direction of the Supervisor, the Behavioral Health Utilization Management (BHUM) Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and experience, the clinician reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the BH UM Reviewer's discretion to retain requests for additional information and/or request clarification. The BH UM Reviewer will use professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases to integrated care management as needed. The BH UM Reviewer will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated. The BH UM Reviewers are responsible to ensure that treatment delivered is appropriately utilized and meets the member's needs in the least restrictive, least intrusive manner possible. The BH UM Reviewer will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit's business and uses clinical judgment in their application. Work Arrangement - Remote role - Monday through Friday from 8:00 AM EST to 5:00 PM EST - Must work 4 out of 10 recognized company holidays to include Thanksgiving and Christmas (rotating) - Must be willing to work 2 to 3 weekends per year. Weekend rotation based on business needs Education & Experience - Registered Nurse candidates: Associate Degree in Nursing required; Bachelor Degree in Nursing preferred - Licensed Social Worker candidates: Master Degree in Social Work required - Minimum of 2 years of independent clinical practice experience assessing and treating individuals with substance use/co-occurring disorders in a clinical setting - Utilization management experience in a managed care organization preferred - Experience working in a remote work environment preferred Licensure - Requirements for LSW: Active and unencumbered professional licensure/independent licensure required in Ohio: LPC, LCSW, LICSW, LISW, LCMHC, LMFT - Must have ability to obtain additional licensure in LA, NC, NH and DC within 12 months from date of hire - Requirements for RN: Active and unencumbered RN license in Ohio and/or compact state nurse license - Must have ability to obtain additional licensure in LA, NC, NH and DC within 12 months from date of hire Skills & Abilities - Proficiency in Microsoft Office, including Word, Excel, Teams, and Outlook - Consistent and accurate typing skills - Ability to communicate in a positive/professional manner both orally and written - Strong problem-solving skills and decision making skills - Strong organizational and time management skills - Ability to follow detailed instructions with a high degree of accuracy - Ability to work independently; complete tasks in the allotted time frame 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. Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Title: Utilization Management Administrative & Operations Program Specialist Location: United States Job Description: Primary Job Function Medical Management ID 44475 For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement. Your career starts now. We are looking for the next generation of health care 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 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, 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. Role Overview As part of the Utilization Management (UM) Administrative Team, the UM Administrative and Operations Program Specialist is responsible for the coordination and ongoing monitoring of UM program objectives, including support of performance improvement projects for service and clinical activities, integrating the quality improvement and efficiencies into all UM department activities. This role implements and supports the overall implementation of UM programs that meet or exceed applicable State, Federal and NCQA standards. Under the direction of UM Leadership, you will support new and existing business through policy writing and updates, development of program documents and updates, development of processes, report development and validation of reports prior to submission. This position also represents UM at Quality meetings to present changes, documents and work-plan required items. Work Arrangement - Remote role - Monday through Friday from 8:30 AM EST to 5:00 PM EST Responsibilities - Responsible for supporting successful development and evaluation of an annual UM work plan and program description by collaborating with corporate and market UM leadership and other areas throughout the organization as necessary - Requests reports both standing and ad-hoc, supports validation of the data upon report completion, Identifies, resolves and/or escalates problematic UM areas to UM leadership, that may impact the department’s ability to achieve annual goals - Participates in the development, implementation and maintenance of UM policies and procedures - Works professionally and efficiently with all functional areas in meeting organizational and departmental UM goals - Collaborates with each Market to ensure policies are created and /or updated in accordance with State, Federal, regulatory and accrediting body’s standard requirements - Ensures timely submission of policy updates, report, and program documents to appropriate committee for approval - Participates on Quality Committees to present reports, policies and/ or program documents that are consistent in meeting regulatory and accrediting body requirements. - Initiates review and submission process for state approval of program documents when state approval is required - Maintains tracking and version control for all policies and standard operating procedures - Participates in New Business Implementation process as assigned to assist with development of program documents, policies, workflows - Serves as a resource for utilization management teams during new business go-live Education and Experience - Associate’s Degree or equivalent work experience required - Bachelor’s Degree preferred - Minimum of 3 years in clinical or service quality improvement required - Minimum of 3 years in healthcare delivery required - Managed health care experience preferred - Successful management of NCQA accreditation survey preferred - Experience with medical management systems, CMS interoperability, Electronic Health Records exp such as Epic, Cerner, Jiva Skills - Excellent organizational, analytical and interpersonal skills - Excellent written and verbal communication skills - Ability to work successfully within all levels of the organization - Ability to design, develop and implement projects to address financial, quality and service improvements - Proficient PC skills in a Windows based environment - Ability to read contracts or legal documents and extract key language to support program and policy development Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Evaluate medical necessity for services, collaborate with providers for timely authorizations, analyze records for compliance, and communicate determinations effectively while maintaining productivity in a high-volume environment.