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Clinical Care Reviewer Utilization Management- AmeriHealth

Company: Amerihealth
Location: Southfield
Posted on: January 21, 2023

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:

  • Associate s Degree RN Diploma.
  • Bachelor s Degree RN 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 setting. BackShareApply Now Associated topics: aseptic, cytometry, dietician, healthcare, histology, kinesiology, microbiological, nephrology, therapy, transfection

Keywords: Amerihealth, Southfield , Clinical Care Reviewer Utilization Management- AmeriHealth, Executive , Southfield, Michigan

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