RN/LMSW, Behavioral Health Clinical Care UM Reviewer, After Hours - REMOTE at AmeriHealth Caritas

About the position The After-Hours Behavioral Health (BH) Utilization Management (UM) Reviewer position at AmeriHealth Caritas is a critical role designed to ensure that members receive appropriate behavioral health care coordination and management services. This position is remote eligible and requires the candidate to work non-traditional hours, specifically during the 3rd shift, to provide access to medical necessity determinations for urgent and contractually required coverage requests on a 24/7, 365 basis. The BH UM Reviewer will be responsible for conducting medical necessity reviews by applying standard operating procedures and pre-determined criteria, utilizing their clinical knowledge and experience to assess provider requests for both inpatient and outpatient services. Under the supervision of the Supervisor, the BH UM Reviewer will work closely with members and providers to gather all necessary information for thorough medical necessity reviews. They will have the discretion to retain requests for additional information and may request clarification when needed. The role requires the application of medical health benefit policy and medical management guidelines to authorize services, while ensuring that treatment is appropriate and meets the member's needs in the least restrictive manner possible. The BH UM Reviewer will also be responsible for recognizing care coordination opportunities and referring cases to integrated care management as necessary. The work schedule for this position is Monday through Friday, with shifts covering the hours between 4 PM and 8 AM. Candidates can choose between working four ten-hour shifts or five eight-hour shifts, with weekend shifts required based on business needs and some holidays also being mandatory. This is a non-exempt (hourly) position, and the successful candidate will be expected to maintain current knowledge of relevant laws, regulations, and policies that pertain to the organizational business units. Responsibilities • Conduct medical necessity reviews for behavioral health services. , • Assist members with specialized behavioral health care coordination and management services. , • Review provider requests for inpatient and outpatient services. , • Collect necessary information from members and providers for thorough reviews. , • Utilize clinical knowledge and judgment to evaluate requests for services. , • Identify and refer requests to the Medical Director when necessary. , • Ensure treatment delivered meets member needs in the least restrictive manner. , • Maintain knowledge of laws, regulations, and policies relevant to the role. , • Work non-traditional hours to provide 24/7 coverage for urgent requests. Requirements • Bachelor's Degree for RN license OR Master's Degree and independently licensed in social work, marriage and family counseling, or professional counseling. , • Minimum of 3 years of experience in behavioral health and/or substance use disorder. , • Experience in Managed Care and Utilization Management is required. , • Must obtain licenses in DC, Louisiana, North Carolina, and Ohio. Nice-to-haves Benefits • Flexible work solutions including remote options and hybrid work schedules. , • Competitive pay. , • Paid time off including holidays and participation in volunteer events. , • Health insurance coverage for employees and their dependents starting day 1 of employment. , • 401(k) plan. , • Tuition reimbursement. Apply Job!