AmeriHealth Caritas Utilization Management Review (Behavioral Health) in Washington, District Of Columbia

Utilization Management Review (Behavioral Health)


Description

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 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 www.amerihealthcaritas.com.

Responsibilities:

Under the direction of the Supervisor, the Clinical Care Reviewer (CCR) 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 Clinical Care Reviewer’s discretion to retain requests for additional information and/or request clarification. The CCR will use his/her 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 CCR 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. CCRs 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 CCR 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.

Education/Experience:

  • Associate’s Degree.
  • Registered Nurse graduate from an accredited institution with an Associate Degree or Bachelor’s Degree. Master’s Degree preferred OR
  • LSW, LPC, LMFT licensure with a Master’s Degree.
  • Minimum 3 years’ experience in a related clinical setting. Managed Care and Utilization Management experience required.
  • Behavioral Health Management experience required.