AmeriHealth Caritas Clinical Care Reviewer Utilization Management in Charleston, South Carolina

Clinical Care Reviewer Utilization Management


Description

Your career starts now. We’re looking for the next generation of health care leaders.

At Blue Cross Complete of Michigan, we’re passionate about helping people get care, stay well and build healthy communities. Based in Southfield, Michigan, Blue Cross Complete is a subsidiary of Blue Cross Blue Shield of Michigan and AmeriHealth Caritas Health Plan. A managed health care organization licensed by the state of Michigan, Blue Cross Complete provides Medicaid health care services in 32 counties. Through the integrated care model of parent company AmeriHealth Caritas we partner with organizations to reduce health disparities and ensure access to the health benefits and services we provide.

We’re seeking talented, passionate individuals to join our team. If you want to make a difference, we’d like to hear from you. As a mission-driven organization, we deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care, community outreach, pharmaceutical benefit management and other administrative services.

Blue Cross Complete of Michigan is an independent licensee of the Blue Cross and Blue Shield Association.

Amerihealthcaritas.com is one of the nation's leaders in health care solutions, offering associates the opportunity to impact the lives of millions of people through a national footprint of products, services and award-winning programs. Located in Philadelphia and operating in 17 states and the District of Columbia, AmeriHealth Caritas serves more than 5.7 million Medicaid, Medicare and CHIP members.

Responsibilities:

Under the direction of the unit Supervisor, 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.

Education/Experience:

  • Current, unrestricted SC Registered Nurse license
  • Minimum 3 years’ experience in Acute care or outpatient clinical setting.
  • Minimum 2 years’ experience in utilization management, preferably within managed care
  • Working knowledge of computers and programs such as internet search engines, Outlook, and Microsoft Office suite.
  • Ability to learn new computer programs and documentation platforms.