Top 12 Document reviewer Jobs in Wilson, Nc

Utilization Management Reviewer
Amerihealth Caritas —United States
- Full-time
- Hybrid work
- Nursing
- Microsoft Outlook
- RN License
- Paid holidays
- Health insurance
Medicare Clinical Appeals Reviewer III
Tanaq Support Services LLC —United States
- Weekends as needed
- Microsoft Word
- Nursing
- Microsoft Excel
Senior Electrical Design Engineer #11518
Ecco Select —United States
- $70 - $85 an hour
- Full-time
- Remote
- 11+ years
- Military encouraged
- Experience equivalent to degree accepted
- Health insurance
- Dental insurance
Quick Apply
3d
Principal Architect - Security
SCA Health —United States
- $150,000 - $185,000 a year
- Full-time
- HIPAA
- Bachelor's degree
- Mentoring
- Disability insurance
- Health insurance
14d

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Utilization Management Reviewer

Amerihealth Caritas -
United States

Apply Now

Job Details

Full-time

Benefits

Paid holidays
Health insurance
Tuition reimbursement
Paid time off

Qualifications

RN License
Associate of Science in Nursing
Pre-authorization review for utilization management
Utilization management
Decision making
Associate's degree
Associate Degree in Nursing

Full Job Description

Role Overview

Our Utilization Management Reviewers evaluate medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Clinical Care Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient’s needs in the least restrictive and most effective manner. The Utilization Management Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making. Productivity expectations include meeting established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment.

Work Arrangement

Candidates are required to work 4 out of 5 days a week at our AmeriHealth Caritas DC office located at 1201 Maine Avenue, S.W., Suite 1000, 10th Floor, Washington DC 20024
Monday through Friday, 8:00 AM to 5:00 PM
4 recognized company holidays to include Thanksgiving and Christmas (rotating)
Weekends based on business needs

Responsibilities

Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines
Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care
Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines
Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions
Identify and escalate complex cases requiring physician review or additional intervention
Ensure compliance with Medicaid and Medicare industry standards
Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment

Education and Experience

Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred
Minimum of 3 years of diverse clinical experience as a Registered Nurse in an Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation or Long-Term Acute Care (LTAC), home health care, or medical office setting
Minimum of 2 years of experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient and/or outpatient services
Experience conducting utilization management reviews for a payor (e.g. Medicaid, Medicare or commercial plan) preferred

Licensure

Active and unencumbered Registered Nurse license required
Active and unencumbered Nurse Licensure Compact (NLC) preferred
Ability to obtain additional RN licensure across the enterprise including the District of Columbia

Skills and Abilities

Proficiency using Electronic Medical Record Systems to efficiently document and assess patient cases
Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance
Working knowledge of InterQual criteria
Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment
Proficiency using MS Office to include Excel, Word, Outlook, and Teams
Ability to type with speed and accuracy

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 include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more.

Apply Now

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document reviewer jobs in wilson, nc

Utilization Management Reviewer

Medicare Clinical Appeals Reviewer III

Senior Electrical Design Engineer #11518

Principal Architect - Security

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