Clinical Care Specialist

3 weeks ago


Philadelphia, Pennsylvania, United States Amerihealth Caritas Health Plan Full time
Job Title: Clinical Care Reviewer, Pediatric Shift Care, Registered Nurse

We are seeking a highly skilled and compassionate Registered Nurse to join our team as a Clinical Care Reviewer for Pediatric Shift Care. As a key member of our team, you will be responsible for managing requests for pediatric shift care services, including skilled nursing and home health aide services, medical daycare, and pediatric residential facilities.

Responsibilities:
  • Manage requests for pediatric shift care services, including skilled nursing and home health aide services, medical daycare, and pediatric residential facilities.
  • Conduct comprehensive assessments of members' medical, behavioral, and social needs.
  • Obtain additional information regarding members and families to support the medical necessity of requested services.
  • Collaborate with physicians, home care agencies, and families to ensure approved services are provided.
  • Refer members to Special Needs/Pediatric Shift Care Case Managers and work collaboratively to ensure continuation of services.
  • Maintain current knowledge and understanding of state contracts, policies, and regulations pertaining to Pediatric Shift Care services.
Requirements:
  • Current, active, and unrestricted Registered Nurse licensure in Pennsylvania.
  • Graduate from an accredited school of nursing. Bachelor's Degree in Nursing preferred.
  • 3+ years providing direct patient care as a Registered Nurse working with medically fragile pediatric patients in a clinical setting.
  • 3+ years of Utilization Management experience, preferably within a managed care organization.
  • Experience utilizing evidence-based clinical decision support tools, such as InterQual, desired.
  • Excellent communication, analytical, and critical thinking skills. Detail-oriented and strong organizational skills.
  • Demonstrated ability to prioritize and multi-task to ensure deadlines for deliverables are met.
  • Working knowledge of MS Office, including Word, Excel, and Outlook, and Internet applications in Windows 10.
  • Proficiency utilizing electronic medical record (EMR) and clinical documentation programs.
What We Offer:
  • Competitive pay and benefits package.
  • Flexible work solutions, including remote options and hybrid work schedules.
  • Opportunities for professional growth and development.
  • A supportive and inclusive work environment.

We are an equal opportunity employer and welcome applications from diverse candidates. If you are a motivated and compassionate Registered Nurse looking for a challenging and rewarding role, please submit your application today.



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