Clinical Care Reviewer Utilization Management- AmeriHealth
Company: Amerihealth
Location: Southfield
Posted on: January 21, 2023
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Job Description:
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 from you.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.
Responsibilities:The Clinical Care Reviewer will be scheduled to
CORE or FLEX hours to provide access to medical necessity
determinations for urgent and contractually required coverage
requests on a 24/7, 365 basis.
Under the direction of the supervisor, the Clinical Care Reviewer
UM is responsible for completing medical necessity reviews. Using
clinical knowledge and experience, the Clinical Care Reviewer UM
reviews the 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 Clinical Care Reviewer UM discretion to pend
requests for additional information and/or request
clarification.The Clinical Care Reviewer UM will use his/her
professional judgment to evaluate the request and ensure that
services are appropriately approved, recognize care coordination
opportunities and refer those cases to Population Health as needed.
The Clinical Care Reviewer UM will apply independent medical
judgment to medical health benefit policy and medical management
guidelines to authorize services and appropriately identify and
refer requests to the Medical Director when indicated. The Clinical
Care Reviewer UM will ensure that treatment delivered is
appropriate and meets the Member s needs in the least restrictive,
least intrusive manner possible. The Clinical Care Reviewer UM will
maintain current knowledge and understanding of and regularly apply
the laws, regulations, and policies that pertain to the
organizational business units and uses clinical judgment in their
application.
This description provides a general overview of the position,
recognizing that day to day duties of each individual in the
position may vary based on personal experience, skills,
supervision, cases and other factors.Education/Experience:
Keywords: Amerihealth, Southfield , Clinical Care Reviewer Utilization Management- AmeriHealth, Executive , Southfield, Michigan
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