PhiladelphiaRecruiter
the smart solution for Philadelphia jobs

Clinical Care Reviewer Utilization Management

Company: Amerihealth
Location: Philadelphia
Posted on: December 9, 2018

Job Description:

Clinical Care Reviewer Utilization Management Job Brief the Clinical Care Reviewer is responsible for completing medical necessity reviewsYour 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 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 .Responsibilities: Under the direction of the unit Supervisor, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse 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 nurse s discretion to pend requests for additional information and/or request clarification. The nurse will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed per Medicare guidelines. The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The nurse may need to follow the same process to review cases on appeal. The nurse 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. Education/Experience:3 or more years' experience in a related clinical setting. Acute Care Emergency Room Critical Care Registered Nurse graduated from an accredited program.Current unrestricted PA Registered Nurse license.Managed care or utilization review experience preferred. Back Share Apply Now

Keywords: Amerihealth, Philadelphia , Clinical Care Reviewer Utilization Management, Executive , Philadelphia, Pennsylvania

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Executive Jobs


Service Manager (Bicycle Mechanic) - Full Time
Description: Company Overview:Our mission is to create products we love and take care of our customers. We value our team, making sure the best is on the field. We also appreciate new ideas from anywhere, inspiring (more...)
Company: Trek Bicycle
Location: Bethlehem
Posted on: 12/20/2018

Vice President, Risk Policy Officer
Description: Vice President, Risk Policy Officer Primary Location: United States,Delaware,WilmingtonEducation: Bachelor's DegreeJob Function: Risk ManagementSchedule: Full-timeShift: Day JobEmployee Status: RegularTravel (more...)
Company: Citi
Location: Wilmington
Posted on: 12/20/2018

Environmental Studies Permitting & Compliance Project Manager
Description: Description Report directly to the Program Manager . This position will serve as the leader for the permitting and compliance monitoring team . In this role the Permitting Environmental Compliance (more...)
Company: Burns & McDonnell
Location: Lancaster
Posted on: 12/20/2018


Clinical Director
Description: Administrative br Brick, NJJob Summary: br Supervises, manages and provides leadership for all clinical staff members as well as the overall clinical operations of the program. br br Responsibilities: (more...)
Company: Pinnacle Treatment Centers, Inc.
Location: Brick
Posted on: 12/20/2018

Case Management Supervisor
Description: Join our team today and immerse yourself in a rewarding career for years to come As a Case Management Supervisor, you will work in an adult case management setting in Cherry Hill, Camden County, NJ. (more...)
Company: Twin Oaks Community Services
Location: Cherry Hill
Posted on: 12/20/2018

3PL Delivery Manager
Description: Company Profile: Employer is one of the largest home delivery, logistics and warehousing companies in the U.S. with over 300 trucks operating in 24 locations. We are proud to serve some of the largest (more...)
Company: Diakon Logistics
Location: Allentown
Posted on: 12/20/2018

Product Manager - Asset Management & Inventory Solutions
Description: The ideal candidate for this role is a creative leader that is savvy in both software and service-based asset management solutions. br br Join Agilent's high growth Laboratory Enterprise Division. (more...)
Company: Agilent Technologies, Inc.
Location: Wilmington
Posted on: 12/20/2018

Office Manager III - Multi Office
Description: Office Manager III - Multi-Unit Are you hellip A driven retail manager with exceptional leadership skills and ability to manage multiple store locations Energized by the opportunity to solve problems, (more...)
Company: H&R BLOCK
Location: Camden
Posted on: 12/20/2018

Retail Store Manager
Description: Job DescriptionMacy 39 s Bridal Salon is looking for a dynamic Store Manager for our location
Company: Bridal Salon at Macy's
Location: Cherry Hill
Posted on: 12/20/2018

Director of Nursing Research and Innovation for Patient Care Services
Description: As one of the nation's leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more (more...)
Company: Nemours Foundation
Location: Wilmington
Posted on: 12/20/2018

Log In or Create An Account

Get the latest Pennsylvania jobs by following @recnetPA on Twitter!

Philadelphia RSS job feeds