Clinical Care Reviewer UM

Clinical Care Reviewer UM

Location: Remote, United States

Primary Job Function: Medical Management

ID**: 31413

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

At AmeriHealth Caritas, we are passionate abouthelping 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 would like to connect with you.

Headquartered in Newtown Square, 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.

MUST BE A FLORIDA RESIDENT

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 Members 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:

• RN Diploma

• RN prefer Bachelor

• Registered Nurse graduated from an accredited program

• Current unrestricted Registered Nurse license

• Valid Drivers 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

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

EOE Minorities/Females/Protected Veterans/Disabled