Clinical Care Reviewer Utilization Management (Registered Nurse)
Posted on: June 11, 2021
Your career starts now. We’re looking for the next generation of
health care leaders.
At AmeriHealth Caritas, we’re passionate about helping people get
care, stay well and build healthy communities. As one of the
nation's leaders in health care solutions, we offer our associates
the opportunity to impact the lives of millions of people through
our national footprint of products, services and award-winning
programs. AmeriHealth Caritas is seeking talented, passionate
individuals to join our team. Together we can build healthier
communities. If you want to make a difference, we’d like to hear
Headquartered in Philadelphia, AmeriHealth Caritas is a
mission-driven organization with more than 30 years of experience.
We deliver comprehensive, outcomes-driven care to those who need it
most. We offer integrated managed care products, pharmaceutical
benefit management and specialty pharmacy services, behavioral
health services, and other administrative services. Discover more
about us at www.amerihealthcaritas.com.
The Clinical Care Reviewer is supervised by a UM Supervisor and
is responsible for evaluating a member’s clinical condition through
the review of medical records (including medical history and
treatment records) to determine the medical necessity for inpatient
and outpatient services based on independent analysis of those
medical records and application of appropriate medical necessity
criteria. The Clinical Care Reviewer is empowered to bind the
company financially by independently authorizing services
determined to be medically necessary based on the independent
review and to refer and consult with a medical director for those
services that do not meet medical necessity criteria. Clinical Care
Reviewers directly interact with providers to obtain additional
clinical information and participate in the development and
modification of medical necessity criteria and policies for the
company and its customers, as well as assisting management with
development of short- and long-term business objectives. Throughout
the performance of their duties, Clinical Care Reviewers provide a
front-line regulatory/compliance function in their evaluation and
application of the criteria. Clinical Care Reviewers are
supported by administrative staff responsible for compiling
information, data entry and other tasks to build cases and
facilitate their work so that Clinical Care Reviewers can focus the
majority of their time on applying their medical knowledge to
medical necessity reviews. This job description is intended
to provide a general overview of the position, while recognizing
that actual day-to-day duties may vary among Clinical Care
Reviewers depending on, as a few examples, their education,
experience, skills, supervisor, and caseload.
Bachelor’s Degree Preferred.
Registered Nurse graduated from an accredited program.
Current unrestricted Registered Nurse license.
Valid Driver’s License and reliable automobile transportation
for on-site assignments and off-site work related activities.
3 or more years’ experience in a related clinical
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