Case Manager Utilization Review Nurse Jobs in Springfield, VA

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

• This role will work 4 days a week in the DC office located at 1201 Maine SW; the 5th day of the week is a remote work day.

• 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 behavioral health/substance use/co-occurring disorders in an inpatient or outpatient acute care setting

• Utilization management experience in a managed care organization preferred

Licensure

• Requirements for LSW: Active and unencumbered professional licensure/independent licensure in DC: LPC, LICSW, LCMHC, LMFT

• Must have ability to obtain additional licensure in LA, NC, NH and OH within 12 months from date of hire

• Requirements for RN: Active and unencumbered RN license in DC

• 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

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.

The targeted hiring range for this role is expected to be between $77,700 and 105,900.The range displayed in this job posting reflects the minimum and maximum for new hire salaries for the position in the D.C. office. Within the range, individual pay is determined by additional factors, including, without limitation, job-related skills, experience, and relevant education, certifications, or training.

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

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 .

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.