AmeriHealth Caritas Manager, Utilization Management Review, Registered Nurse in Philadelphia, Pennsylvania

Manager, Utilization Management Review, Registered Nurse

Location: Philadelphia, PA

Telecommuter?: No

ID**: 12988

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

Reporting to the Regional Director of Utilization Management this position is responsible for leading, directing and overseeing the clinical coordination components of the Utilization Management Program. Works in close collaboration with all departments to achieve optimal care and services for all members.

The primary purpose of the job is to:

  • Direct activities of the Utilization Management staff. Oversee staff performance with regard to prior authorization, medical necessity determinations, concurrent review, retrospective review, continuity of care, care coordination, and other clinical and medical management programs. These responsibilities extend to behavioral health care services.

  • Ensure effective daily operation of the Utilization Management Department utilizing all applicable statutory provisions, contracts and established policies and administrative procedures.

  • Maintain optimal staffing patterns based on contractual obligations and current Utilization Management budget. Comply with all policies and procedures for personnel requisitions, interviews and employment. Maintain accurate position control and organizational chats of assigned departments.

  • Participate in the State’s Drug Utilization Review (DUR) Board Meeting and Mental Health Quality Assurance Committee as invited.

  • Partake in internal pharmacy therapeutic committee and work closely with the Directors of Pharmacy, pharmacy benefits manager (PBM), and the State’s PBM team.

  • Prepare reports and conduct analysis of operations / services as required by departmental, corporate, regulatory, and State requirements. Work collaboratively with Information Services Department on identifying required data for reporting.

  • Assist in preparation, coordination, and follow up of Utilization Management audits, such as readiness review and DHH site visits, pertaining to the Utilization Management Department.

  • Partner with community agencies and contracted vendors to develop and maintain collaborative contact to assure members have access to the appropriate resources and to avoid duplication of efforts.

  • Act as a liaison with outside entities, including but not limited to physicians, hospital, health care vendors. social services agencies, member advocates, DHH and other Care entities.

  • Participate in coordination of internal and external Provider and Member directed communication regarding issues impacting Utilization Management coordination and delivery, such as medication management, use of generic medications, etc.

  • Establish performance and productivity requirements and communicate expectations to management team. Work collaboratively with Supervisor in identification of individual and / or group deficiencies in scheduled Performances Reviews. Establish action plan for assessment and resolution of identified issues.

  • Oversee the collaborative efforts of the Supervisors to ensure that all new and existing staff are oriented to organizational and department policies and procedures. Ensure that credentials of all licensed staff are verified in accordance with licensing agency initially and prior to expiration date. Maintain current and accurate files of such licensure and ongoing education status. Ensure that staff meets minimal skill and clinical knowledge requirements to be successful in assigned role.

  • Participate in current process review and development of new and / or revised work processes, policies and procedures relating to Utilization Management responsibilities. Provide input into the development of educational material and programs necessary to meet business objectives, members’ needs, contractual and regulatory guidelines and staff professional development

  • Comply with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information

  • Develop and maintain department budget. Seek opportunities to contain cost.


  • Current and unrestricted Registered Nurse licensure required.

  • Bachelor's Degree required.

  • 3+ years in leadership role (Supervisor or above) within a utilization management department, preferably within a managed care organization.

  • 3 to 5 years of relevant clinical practice within an acute care setting or managed care organization.

  • Demonstrated competency utilizing healthcare data (e.g. developing/maintaining reports to facilitate change and/or increase productivity within the department.

  • Demonstrated ability to develop/improve process improvement to achieve contractual compliance by collaborating with departments across an organization.

  • Successfully demonstrate the ability to communicate up and down layers of an organization.

  • Proficient in MS Office within a Windows-based environment, Citrix, JIVA, Streamline, and SharePoint. Familiarity with Interqual criterion and electronic medical record and documentation programs.

EOE Minorities/Females/Protected Veterans/Disabled