The Off Shift Clinical Care Reviewer will be scheduled to work non-traditional hours to provide access to medical necessity determinations for urgent or contractually required coverage requests on a 24/7, 365 basis. The Off-Shift Clinical Care Reviewer will be required to work 1 Summer holiday and 1 Winter holiday. Weekday coverage hours for the team is 5 p.m. - 8:00 a.m.
Under the direction of the Medical Management Manager, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nurse's discretion to pend requests for additional information and/or request clarification. The nurse 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 nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The nurse 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. .
Registered Nurse required.
Current unrestricted PA Practical Nurse license or PA Registered Nurse license.
3 or more years experience in a related clinical setting.
Managed care or utilization review experience preferred.
Valid Driver's License and reliable automobile transportation for on-site assignments and off-site work related activities.
Amerihealth Caritas Health Plan