Clinical Review Specialist

4 weeks ago


Harrisburg, Pennsylvania, United States Capital BlueCross Full time
Job Summary

We are seeking a licensed clinical professional to join our Utilization Management team at Capital Blue Cross. As a Clinical Review Specialist, you will play a critical role in processing acute and post-acute inpatient medical or behavioral health requests through clinical review and the application of approved medical necessity criteria.

This is a unique opportunity to utilize your expertise in a high-acuity setting, working closely with UM department staff and Care Management professionals on discharge planning and transition of care activities.

About the Role:

  • Key Responsibilities:
    • Process acute and post-acute inpatient medical or behavioral health requests through review of submitted requests and applicable clinical records.
    • Interpret and apply medical necessity criteria to determine medical necessity and appropriateness of requested services.
    • Perform high acuity of care UM case reviews within the framework of applicable regulatory requirements and established policies and procedures.
  • Requirements:
    • A minimum 5 years of experience working in a higher level of care clinical role, including acute care hospitals and post-acute care facilities.
    • 1 year of UM experience in managed care.
    • Active current and unrestricted Registered Nurse licensure in Pennsylvania.
    • Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification within 2 years of employment.

Estimated Salary: $85,000 - $110,000 per annum

Why Work with Us: At Capital Blue Cross, we prioritize your health and wellbeing, fostering a flexible environment where you can grow professionally and personally. Join our diverse and caring team and be encouraged to volunteer in your community.



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