AmeriHealth Caritas Clinical Care Reviewer, Utilization Management, Registered Nurse in Philadelphia, Pennsylvania
Clinical Care Reviewer, Utilization Management, Registered Nurse
Location: Philadelphia, PA
Primary Job Function: Medical Management
Your 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 www.amerihealthcaritas.com .
The Clinical Care Reviewer is supervised by a Utilization Management Supervisor and is responsible for evaluating a member’s clinical condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for inpatient and outpatient services based on independent analysis of those medical records and application of appropriate medical necessity criteria. The Clinical Care Reviewer is empowered to bind the company financially by independently authorizing services determined to be medically necessary based on the independent review and to refer and consult with a medical director for those services that do not meet medical necessity criteria. Clinical Care Reviewers directly interact with providers to obtain additional clinical information and participate in the development and modification of medical necessity criteria and policies for the company and its customers, as well as assisting management with development of short- and long-term business objectives. Throughout the performance of their duties, Clinical Care Reviewers provide a front-line regulatory/compliance function in their evaluation and application of the criteria. Clinical Care Reviewers are supported by administrative staff responsible for compiling information, data entry and other tasks to build cases and facilitate their work so that Clinical Care Reviewers can focus the majority of their time on applying their medical knowledge to medical necessity reviews. This job description is intended to provide a general overview of the position, while recognizing that actual day-to-day duties may vary among Clinical Care Reviewers depending on, as a few examples, their education, experience, skills, supervisor, and caseload.
Current and unrestricted Registered Nurse license.
Associate’s Degree. Bachelor’s Degree preferred.
3 or more years’ clinical experience preferably in an ICU or ED.
Utilization management experience preferably within a managed care organization.
Familiarity with Interqual (preferred).
Proficiency utilizing MS Office (Word, Excel, and Outlook) in Windows 10 in addition to utilizing electronic medical record and documentation programs.
Valid Driver’s License and reliable automobile transportation for on-site assignments and off-site work related activities.
This position will be based in our office at 100 Stevens Drive, Building 200, Philadelphia, PA 19113 once our remote work mandate is lifted.
EOE Minorities/Females/Protected Veterans/Disabled