Under the direction of the unit Supervisor/Manager, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and experience, the clinical care reviewer will review provider requests for inpatient and outpatient services physical and behavioral services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review upon appeal. It is within the clinical care reviewer's discretion to pend requests for additional information and/or request clarification. The reviewer will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed. The reviewer will apply medical health benefit and behavioral health policy and medical/behavioral management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The reviewer will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit's business and uses clinical judgment in their application.
Experience and education:
3 or more years experience in a related clinical setting or appeals.
Managed care or utilization review experience preferred.
Excellent oral and written communication skills.
Ability to identify problems and recommend solutions.
Self-directed/Ability to work independently.
Excellent decision making skills.
Excellent time management skills, prioritizing work and meeting timelines.
Ability to advocate for member/member family needs.
Dedicated to meeting the expectations and requirements of internal and external customers.
Obtains continuing education required to maintain professional licensure.
Ability to achieve required performance results on all audits and Inter Rater Reliability (Peer to Peer).
Current unrestricted Registered Nurse license.
Registered Nurse graduate from an accredited institution with an Associate Degree or Bachelor's Degree.
Master's Degree preferred OR LSW, LPC, LMFT unrestricted licensure with a Master's Degree
Amerihealth Caritas Health Plan