AmeriHealth Caritas Clinical Care Reviewer, Concurrent Review, Registered Nurse in Philadelphia, Pennsylvania
Clinical Care Reviewer, Concurrent Review, Registered Nurse
Location: Philadelphia, PA
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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 www.amerihealthcaritas.com .
Under the supervision of the Supervisor, Utilization Management, the Clinical Care Review Nurse is responsible for completing medical necessity reviews using Plan policies and procedures, reviewing inpatient and outpatient elective procedures requiring prior authorization, inpatient hospital stays, and requesting, assessing and appropriately channeling/facilitating discharge planning requests Consistently applies medical health benefit policy and medical management guidelines to authorize services. Identifies and refers requests for services to the appropriate Medical Director when guidelines are not met.
Receives requests for authorization of services, including inpatient hospital admissions, inpatient rehabilitation services, Skilled Nursing admission), home care home infusion services, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non-participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).
Verifies and documents member eligibility for services.
Communicates and interacts in a real time bases via “live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).
Utilize technology and resources (systems, telephones, etc.) to appropriately support work activities. Voice mail as an adjunct to the daily work activities versus major reliance for giving and receiving information from providers; Accessing and applying Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.
Applies submitted information to Plan authorization process (utilizing Interqual Evidence -based guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.
Coordinates with the referral source if insufficient information is not available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows Plan process for requesting additional information.
Refers cases to Plan Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.
Documents case activities for Utilization determinations and discharge planning in JIVA in a real time manner (as events occur). Completes detail line as indicated.
Provides verbal/fax denial notification to the requesting provider as per policy. Generates denial letter in a timely anner.
Assesses episodes of care for Discharge Planning needs and interventions.
Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)
Submits appropriate documentation/clinical information to clerical support for record keeping and documentation requirements.
Recognizes opportunities for referrals to Care Coordination Department, and refers accordingly.
Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.
Maintains awareness and complies with Plan authorization timeliness standards based on DHS/NCQA requirements.
Meets audit expectations according to benchmarks.
Current and unrestricted Pennsylvania RN licensure.
Minimum of 5 years of nursing experience as a Registered Nurse, in related clinical setting, preferably critical care (e.g. ER, ICU).
2-3 years of experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization.
Familiar with Interqual Criterion.
Knowledge of CPT, HCPC's ICD 9 coding system, DRG classification.
Working knowledge of MS Office including Word, Excel, and Outlook in a Windows based environment. Proficient utilizing electronic medical record and documentation programs
EOE Minorities/Females/Protected Veterans/Disabled