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Clinical Care Reviewer
2 months ago
Position: Clinical Care Reviewer - Utilization Management
Location: Remote
Primary Function: Medical Management
Overview:
Your professional journey begins here. At AmeriHealth Caritas, we are dedicated to empowering individuals to access care, maintain wellness, and foster healthy communities. As a prominent entity in health care solutions, we provide our team members with the chance to make a significant impact on the lives of countless individuals through our extensive range of products and services.
AmeriHealth Caritas, headquartered in Newtown Square, is a mission-focused organization with over three decades of experience in delivering comprehensive, outcome-oriented care to those in need. Our offerings include integrated managed care products, pharmaceutical management, specialty pharmacy services, behavioral health services, and various administrative functions.
Key Responsibilities:
The Clinical Care Reviewer will be scheduled for CORE or FLEX hours to ensure timely access to medical necessity evaluations for urgent and contractually mandated coverage requests on a 24/7 basis.
Under the guidance of a supervisor, the Clinical Care Reviewer is tasked with conducting medical necessity assessments. Utilizing clinical expertise, the reviewer evaluates provider requests for both inpatient and outpatient services, collaborating closely with members and providers to gather all necessary information for a comprehensive review. The reviewer has the discretion to defer requests for additional information or seek clarification as needed.
Applying independent medical judgment, the Clinical Care Reviewer will assess requests to ensure that services are appropriately authorized, identify care coordination opportunities, and refer cases to Population Health when necessary. The reviewer will also ensure that the treatment provided aligns with the Member's needs in the least restrictive manner possible. It is essential for the reviewer to stay informed about relevant laws, regulations, and policies that govern the organization and to apply clinical judgment accordingly.
This role offers a unique opportunity to thrive in a collaborative and team-oriented environment.
Qualifications:
- Must possess a valid Registered Nurse license in Ohio or a compact state.
- Associate's Degree is required; a Bachelor's Degree in Nursing is preferred.
- Registered Nurse must have graduated from an accredited nursing program.
- A minimum of 3 years of clinical experience as a RN in Emergency Department, Intensive Care Unit, Medical-Surgical, or post-acute care settings is required.
- At least 1 year of experience in Utilization Management within a Managed Care Organization is preferred.
- Proficiency in utilizing Interqual criteria is preferred.
- Must be adept in using MS Office applications (Word, Excel, Teams, Outlook) in a Windows environment, as well as electronic medical record systems.
- Demonstrated ability to work independently in a remote setting.
- Availability to meet scheduling requirements, including working on recognized holidays.
- Willingness to work occasional overtime and weekends based on business needs.
Diversity, Equity, and Inclusion:
At AmeriHealth Caritas, we strive to create an environment where everyone feels valued and supported. Our commitment to equity ensures that all associates have the opportunity to reach their full potential. We actively promote integrity and respect, standing against injustice and working to eliminate barriers to create a more inclusive workplace. Embracing diverse perspectives enhances our organization, making us more innovative and better equipped to serve our communities.
Benefits:
We prioritize the well-being of our associates, offering a comprehensive benefits package that includes flexible work arrangements, competitive compensation, health insurance coverage from day one, a 401(k) plan, tuition reimbursement, and generous paid time off.
AmeriHealth Caritas is an equal opportunity employer, welcoming applications from all individuals regardless of race, gender, veteran status, or disability.
