AmeriHealth Caritas Supervisor Utilization Management Review in Philadelphia, Pennsylvania

Supervisor Utilization Management Review


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Headquartered in Philadelphia, 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


Under the supervision of the Manager of Utilization Management/ Appeals, is responsible to provide workflow and clinical direction, organization and monitoring of all UM services especially appeals. The Supervisor is a clinician with customer service, interpersonal and problem-solving skills. He/She is responsible for the day to day operation of the Appeals Department to ensure compliance with departmental, state, federal and NCQA requirements. Under the general supervision of the Appeals Manager the supervisor communicates with all KMHP/AMHP departments to interpret and enhance understanding of the policies and procedures for provider appeals and member complaint and grievance.

Oversight of day to day operation of the Appeals Department to ensure department performance standards are met.

  • Assists/supports appeal staff in meeting individual as well as departmental goals and objectives by performing quality assessments of work and providing appropriate and timely feedback.
  • Performs medical and administrative review on identified provider appeals in a timely manner.
  • Supervises staff when preparing and presenting appeal cases to the Appeals Panel.
  • Maintains a current knowledge of all HealthChoices contracts regulations, Keystone Mercy Health Plan Policy and Procedures, DPW requirements, NCQA/URAC Standards affecting care assessment, access, case management, prior authorization, inpatient review, discharge planning, home health, Durable Medical Equipment and Appeal services.
  • Reviews all Provider rand Member appeal determination letters for accuracy.
  • Complies with Keystone Mercy Health Plan, DPW and HIPPA confidentiality requirements and protect member’s personal and identifiable health information.
  • Provides advisory and clinical support to Utilization staff, including the interpretation of regulatory requirements, policies, and procedures to assure consistency and accuracy.
  • Participates in interdepartmental meeting related to the customer satisfaction and process improvements.
  • Keeps current with rules, regulations, policies and procedures relating to KMHP/AMHP member benefits, rights, responsibilities, and Complaints and Grievances.
  • Provides appeals training for Member/ Provider Services staff and other departments.
  • Works with grievance coordinators on difficult cases. Is a resource person for policy and procedures interpretation.
  • Fosters and maintains open communication vertically and horizontally within the organization.
  • Acts as a liaison for Keystone Mercy Health Plan with outside entities, including, but not limited to physicians, hospitals, health care vendors, social service agencies, member advocates, and regulatory agencies.
  • Maintains strict confidentiality of member, provider and employee information.
  • Completes performance evaluations of assigned staff. Participates in performance improvement plans and employee counseling as needed. Provide regular and ongoing feedback to maintain acceptable production and quality levels.
  • Maintains a current and active professional Nursing license. Obtains continuing education required for licensure and to perform responsibilities successfully.
  • Performs all personnel functions for department's employees. Maintains complete and accurate personnel records and conducts performance appraisals as indicated by company standard for performance review.
  • Monitors for and identifies individual and/or group deficiencies in productivity; policy, procedure and/or regulatory standards & performance audits. Will work with manager to implement a corrective action plan and will monitor progress.
  • Performs other related duties and projects as assigned including but not limited to committee participation.
  • Adheres to KMHP policies and procedures and supports and carries out the Mercy Mission and Values.

Key Competencies/Success Factors:

  • Budgetary Responsibility – Seeks opportunities to contain cost and increase profitability.
  • Corporate Financial Performance – Assists in the establishment and achievement of business objectives for the area of responsibility based upon company’s overall strategic plan & yearly operating goals.
  • Performance Management –Holds self and others accountable to goals and standards of department and company.
  • Employee Training and Development – Guides and encourages career development, conducts timely performance evaluations and provides open/ongoing constructive feedback to all direct reports.
  • Leadership Skills – Leads by example: Sets an example of personal performance, which encourages excellence and integrity. Advocacy, Competence, Dignity, Stewardship, care of the Poor, Hospitality, Compassion and Diversity. Role models Mission and Values and promotes excellence in customer service through personal actions.
  • Job Knowledge – Maintains current knowledge of and applies all applicable licensing, regulatory and industry standards. Keeps abreast of current industry trends.
  • Communication Skills – Writes, speaks and presents clearly and concisely. Is thoroughly prepared prior to beginning any negotiation or conflict resolution process.
  • Regulatory and Delegation Compliance – Assess departments work quality and develops/implements process improvements to improve and achieve regulatory and oversight compliance.
  • Analytical Skills – Analyzes data and makes sound, logical and timely decisions. Establishes priorities and sets long and short term goal

ADA Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • The position requires being seated for several hours a day.
  • The employee must frequently talk and hear, as well as utilize the telephone, computer and computer printer, facsimile machine, printer, Xerox machine, pen and paper.
  • The employee is occasionally required to walk, travel by car, bus, train, or plane.
  • The employee must occasionally present to small groups.


  • Registered Nurse graduated from an accredited Diploma, Associate’s Degree or Bachelor’s Degree program required. Bachelor’s Degree in Nursing or Health related field preferred.
  • Minimum five years progressively responsible experience in a clinical environment, including utilization management, case management, appeals and/or discharge planning experience. Previous experience in managed care required. Medical Assistance experience preferred.
  • Minimum of four years management experience.
  • Current Pennsylvania Registered Nurse License required. Valid driver’s license required (and reliable transportation for requested offsite work related act ivies).
  • Proficiency with Microsoft Office Suite (Word, Excel, Power Point). Access is a plus. Consistent word processing speed and accuracy of 50 or more words per minute.
  • Unrestricted and current Registered Nurse (RN) license.