Philadelphia - PA Full Time 2 weeks ago

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 [Link available when viewing the job].

This role is eligible for a $5,000 sign-on bonus

The Off – Shift Clinical Care Reviewer will be scheduled to work non-traditional hours to provide access to medical necessity determinations for urgent or contractually required coverage requests on a 24/7, 365 basis. The Off-Shift Clinical Care Reviewer will be required to work 1 Summer holiday and 1 Winter holiday.

Under the direction of the Medical Management Manager, 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 Registered Nurse license.
  • 3 or more years experience in a related clinical setting.
  • Managed care or utilization review experience, specifically Concurrent Review and Prior Authorization experience.
  • Must be able to work between 5p and 8a, 12 hour or 8 hour shifts, depending on the business and scheduling needs.
  • Must be able to work 12 hour shifts on weekends, depending on the business and scheduling needs. 
  • Working knowledge of InterQual criterion.
  • Familiarity with electronic medical record and documentation programs.
  • Basic working knowledge of Windows and MS Office Suite (Word, Excel, and Outlook).
  • Valid Driver’s License and reliable automobile transportation for on-site assignments and off-site work related activities.
  • This position may require holidays and/or weekend hours. 
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