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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

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