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.

Role Description Responsible for managing the end-to-end credentialing process for physicians and advanced practice providers, ensuring confidentiality, regulatory compliance, and coordination with hospital leadership and committees. Will oversee documentation, resolve issues, and guide files through approval channels, including departmental and board-level reviews. - Plan and organize workload for all new appointments and reappointments. - Identify and resolve issues in the credentialing and privileging process. - Manage committee approval process and meet credentialing deadlines. - Collaborate with CCO and departments to review provider status and red flags. - Maintain confidentiality of provider information and credentialing files. - Ensure compliance with TJC, CMS, URAC, NCQA, and other regulations. - Prepare and present credentialing packets to departmental committees. - Update records post-appointment and respond to regulatory inquiries. - Generate reports and forecast workload to meet regulatory timelines. Qualifications - Bachelor's Degree Related Field of Study preferred - 3-5 years of Credentialing & Privileging, Medical Staff Services required - 3-5 years of experience with MD-Staff preferred - Working knowledge of general office practices and software applications and database management. - Demonstrated understanding of credentialing policies and procedures, as well as accreditation and regulatory requirements relating to the medical staff. - Strong organizational skills. - Ability to manage demanding workload; self-motivated; able to carry out responsibilities with minimum supervision. - Strong analytical skills. - Strong interpersonal skills to effectively communicate with cross-functional teams including staff at all levels of the organization. - Ability to successfully negotiate and collaborate with others of different skill sets, backgrounds and levels within and external to the organization. Requirements - Remote Type: Remote - Work Location: 399 Revolution Drive - Scheduled Weekly Hours: 40 - Employee Type: Regular - Work Shift: Day (United States of America) - Pay Range: $63,648.00 - $90,750.40/Annual - Grade: 6 Benefits At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth.

Role Description Reviews appraisals and reports including desktop valuations from a wide variety of bank channels. Reviewer Appraiser positions review all types of residential appraisal reports, including complex and small income properties located throughout the country. Valuations are reviewed for accuracy, consistency and to ensure they are USPAP compliant, well supported and credible. Analyzes quality and statistical data for the assigned property under review. Develops a summary of collateral and communicates to the customer for the lending decision. Qualifications - High school diploma or equivalent - Six or more years of related appraisal experience - Valid, active license to appraise with qualifications as determined by state requirements Requirements - Extensive knowledge of appraisals and the appraisal process, including Government Sponsored Entities, USPAP and U.S. Bank policy and procedures - Excellent verbal and written communication skills - Strong analytical and decision-making skills - Ability to manage multiple tasks/projects and deadlines simultaneously - Proficient computer navigation skills using a variety of software packages including Microsoft Office applications - Appraisal Review experience Benefits - Healthcare (medical, dental, vision) - Basic term and optional term life insurance - Short-term and long-term disability - Pregnancy disability and parental leave - 401(k) and employer-funded retirement plan - Paid vacation (from two to five weeks depending on salary grade and tenure) - Up to 11 paid holiday opportunities - Adoption assistance - Sick and Safe Leave accruals of one hour for every 30 worked, up to 80 hours per calendar year unless otherwise provided by law

Role Description The Cardiologist, Virtual Care serves as a virtual health-care provider who specializes in diagnosis, management, and follow-up of patients with any suspected or known heart diseases. The role involves moderately complex to complex issues requiring in-depth evaluation of variable factors. - Specializes in diseases of the heart and blood vessels. - Part of a clinical care team focusing on outpatient medicine, continuity of care, health maintenance, and disease prevention for elderly patients. - Manages complex cardiac conditions such as: - Heart attacks - Abnormal heartbeat rhythms - Congestive heart failure - Provides preventative techniques for potential heart-related illnesses. - Spends 100% of time clinically focused on direct patient virtual care, including patient-facing time and general administrative tasks related to direct patient care. Qualifications - Medical degree and 5+ years of residency and fellowship experience. - Licensure requirements of the state of jurisdiction. - Graduate of accredited MD or DO program of accredited university. - Certified by the American Board of Internal Medicine with a certificate of special qualification in cardiovascular disease. - Certified by the American Board of Nuclear Medicine with a certificate of special qualification in echocardiography. Requirements - This role is considered patient-facing and is part of Humana/Senior Bridge's Tuberculosis (TB) screening program. - If selected for this role, you will be required to be screened for TB. - Occasional travel to Humana's offices for training or meetings may be required. Benefits - Competitive benefits that support whole-person well-being. - Medical, dental, and vision benefits. - 401(k) retirement savings plan. - Time off including: - Paid time off - Company and personal holidays - Volunteer time off - Paid parental and caregiver leave - Short-term and long-term disability. - Life insurance and many other opportunities. Company Description CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment, and more. Our unique care model focuses on personalized experiences, taking time to listen, learn, and address the factors that impact patient well-being. - Integrated care teams spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. - Focus on whole health and addressing the physical, emotional, and social wellness of our patients.