RN license required. UM experience preferred in Exchange / ACA product or commercial insurance. This position will also be actively reviewing cases.
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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.
Under the supervision of the Manager for Utilization Management, this position is responsible for providing daily oversight of UM Nurses, UM Technicians and staff members within Utilization Management. Responsibilities include providing clinical, technical and operational support and direction, including organization and monitoring of all medical services. Responsible for direct supervisory oversight of professional and front line staff receiving requests for authorizations from external customers which encompasses providers and members, as well as from the internal customers. This position will also be actively reviewing cases.
- Assists with the daily operations of licensed and non-licensed professionals on the Utilization Management team.
- Monitors staff work assignments and makes appropriate adjustments based on staffing levels, staff experience, and number/request types of authorizations/appeals received.
- Provides coaching and counseling to improve productivity of staff members within Utilization Management.
- Assesses candidates and ensures that optimal qualifications are met as a member of the department’s interview team.
- Plans, develops and supports or conducts orientations, training programs and creates educational material for staff members to improve skills, aid in professional growth and development and to ensure staff’s expertise.
- Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education and counseling to improve performance.
- Works collaboratively with the Manager and identified leadership to develop and implement performance measures, and monitors associates placed on performance improvement plans.
- Responsible for writing and finalizing annual reviews for direct reports with Manager input.
- Participates in process reviews and the development of new and/or revised work processes, policies and procedures relating to Utilization Review.
- Accurately answers questions regarding Plan benefits for members and providers.
- Acts as a liaison with outsides entities, including, but not limited to, physicians, hospitals, health care vendors, social service agencies, member advocates, and regulatory agencies.
- Creates and supports an environment that fosters teamwork, cooperation, respect, and diversity.
- Establishes and maintains positive communication and professional demeanor with internal and external customers, providers and members at all times.
- Stays current with ACFC policies and procedures and Medicare requirements
- Bachelor’s Degree Nursing preferred, Associate's Degree minimum
- Unrestricted, current RN license.
- Previous experience with Commericial and / or ACA / Exchange products
- 3-5 years progressive experience in an acute care setting or equivalent experience. Minimum 3 years of experience in managed care utilization review preferred.
- Proficiency with Microsoft Office Suite (Word, Excel, Power Point). Access is a plus. Consistent word processing speed and accuracy of 50 or more words per minute.