Remote Utilization Review Manager Jobs in Rutherfordton, NC

Work Arrangement

This position is a remote field based position. Will make face to face visits to members in the Upstate Region, primarily in the Cherokee and Greenville counties.

Role Overview:

Responsible for managing and coordinating care, services, and social determinants of health for Members with behavioral health conditions and acute, chronic, and medically complex needs. Serves as the primary point of contact for the care team that includes Members, physicians as well as community supports to guide members in achieving their optimal level of health. Utilizes strong assessment and communication skills, critical thinking, and clinical knowledge to identify issues, gaps in care, and barriers to care. The Behavioral Health Case Worker develops a plan of care through shared decision-making with the Member/caregiver and in collaboration with providers and other care team members to improve the Member's health status and compliance with treatment plans and promote self-management.

• Support Members during transitions of care through assessment, coordination of care, education of the discharge plan of care, referrals, and evaluation of the plan's effectiveness.
• Review the medication list and help members coordinate pharmacy needs with a community pharmacist to ensure medication reconciliation is completed when any changes occur.
• Evaluate, monitor, and update the care plan through regularly scheduled follow-up contacts based on the Member/caregiver's progress, needs, and preferences.
• Establishes points of contact in order to collaborate with identified community, medical, and/or behavioral health teams.
• Maintain timely, complete, and accurate documentation of Member interactions in ACFC electronic care management platforms where applicable.
• Monitor appropriate utilization and coordinate services with other payer sources, make appropriate referrals, and identify and escalate quality of care issues.
• Develop a working knowledge of ACFC electronic care management platforms, care management programs, policies, standard operating procedures, workflows, Member insurance products and benefits, community resources and programs, and applicable regulatory, state, and NCQA requirements.
• May identify cases to be presented at care management rounds and follow up with providers on recommendations to achieve optimal outcomes for Members.
• Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse Member population.
• Conduct Face-to-face visits at the Member's residence, provider's office, hospitals, other acute locations, or community locations for education and/or assessment.

• Travel required. Must have valid driver's license, reliable transportation and auto insurance.

Education/Experience:

• Required Bachelor's Degree in related field (i.e., social work, health science, psychology, sociology, early childhood education, etc.). Masters prepared will be given preferred consideration.
• 2 years of proven professional experience working directly with SMI members (Serious Mental illnesses) aged six and up who may have one of the following conditions: Psychotic Disorders, Bipolar Disorders, Major Depression.
• 2 years of social services experience, engaging with clients (e.g., individuals, families, communities), routinely assessing their needs, connecting them to services, and monitoring their progress.
• Proficiency using MS Office (Word, Excel, Outlook), internet applications, and electronic medical record and documentation programs. Electronic Case Management Platform (i.e. Jiva)
• Strong documentation and record-keeping skills are required, emphasizing accuracy and adherence to established methods.

• Proven professional expertise in assessing members' situations, developing care plans, and teaching self-management. in assessing member's situation, developing a care plan, and teaching self-management. Skilled in working one-on-one with members, effectively communicating preventative health and management philosophies, and presenting health education materials to both individuals and small groups.

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.

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.

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.