Clinical Care Reviewer, Utilization Management, Off Shift
Company: Amerihealth
Location: Philadelphia
Posted on: April 10, 2021
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Job Description:
Your career starts now. Were looking for the next generation of
health care leaders. At AmeriHealth Caritas, were 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, wed 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: The Off Shift
Clinical Care Reviewer will be scheduled to work non-traditional
hours to provide access to medical necessity determinations for
urgent or contractually required coverage requests on a 24/7, 365
basis. The Off-Shift Clinical Care Reviewer will be required to
work 1 Summer holiday and 1 Winter holiday. Under the direction of
the Medical Management Manager, 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 nurses 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. 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 will maintain current knowledge and
understanding of the laws, regulations, and policies that pertain
to the organizational units business and uses clinical judgment in
their application. EDUCATION/EXPERIENCE: * Current unrestricted PA
Registered Nurse license. * 3 or more years experience in a related
clinical setting. * Managed care or utilization review experience
preferred. * Valid Drivers License and reliable automobile
transportation for on-site assignments and off-site work related
activities. Back [ Share * * * * * Apply Now [
Keywords: Amerihealth, Philadelphia , Clinical Care Reviewer, Utilization Management, Off Shift, Healthcare , Philadelphia, Pennsylvania
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