AmeriHealth Caritas Clinical Care Reviewer Utilization Management in Charleston, South Carolina
Clinical Care Reviewer Utilization Management
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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
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.
- Current, unrestricted SC Registered Nurse license
- Minimum 3 years’ experience in acute care and/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
- Ability to learn new computer programs and documentation platforms
EOE Minorities/Females/Protected Veterans/Disabled