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, Pennsylvania, 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.
Responsibilities:
- 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 physical and behavioral health care and transportation 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.
- 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 OMPP 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, OMPP and other Care Select 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.
Education/Experience:
- Bachelor’s Degree.
- Current and unrestricted Registered Nurse licensure in Pennsylvania or compact state license required.
- 3+ years of clinical experience as a Registered Nurse required.;
- Experience leading a large, remote team of clinical professionals and administrative support staff, preferably within a managed care organization (MCO).
- 3+ years of experience performing utilization management reviews (prior authorization and concurrent review) as a Registered Nurse within a managed care organization desired.
- Experience in use of financial information for planning purposes.
- Demonstrated ability to assess department’s work quality and develop/implement process improvements to achieve contractual and oversight compliance.
- Ability to maintain current knowledge of company policy and procedures, Interqual criteria, access and delivery of services.
- Demonstrated understanding of managed care and impact on services including but not limited to, prior authorization, inpatient review, discharge planning, home health, and SNF/Rehabilitation Services.
- Demonstrated competency in use of healthcare data.
- Excellent analytical and problem solving skills
- Strong computer skills. ;Proficiency and speed working in all Microsoft Office Suite applications as well as electronic medical record and documentation programs.
- Understanding of and expertise in quality improvement and medical economics.
- Valid Driver’s license and clean driving record required; reliable transportation and appropriate auto insurance necessary.
Diversity, Equity, and Inclusion
At Amerihealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
We keep our associates happy so they can focus on keeping our members healthy.
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.
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