Position Details:

Client : AmeriHealth

Job title : Clinical Care Reviewer - UM

Location : 4390 Belle Oaks Drive, North Charleston, SC, 29405

Duration : 3 Months

Duties:

• 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.


• Excellent oral and written communication skills.


• Ability to identify problems and recommend solutions. Self-directed/Ability to work independently.


• Excellent decision making skills.


• Excellent time management skills, prioritizing work and meeting timelines. Ability to advocate for member/member family needs.


• Dedicated to meeting the expectations and requirements of internal and external customers.


• Obtains continuing education required to maintain professional licensure.


• Ability to achieve required performance results on all audits and Inter Rater Reliability (Peer to Peer). Physical Effort/Working Conditions


• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job. Primarily works in a climate controlled office based setting.

Skills:

Registered Nurse

• Current state unrestricted RN license.

• 3 or more years experience in a related clinical setting.

Education:

• Registered Nurse graduated from an accredited programBSN

Preferred Skills and Experience:

Required Skills:

• AUDITS

• SELF-DIRECTED

• TIME MANAGEMENT

• AUDIT

• MEDICAL MANAGEMENT

Additional Skills:

• OUTPATIENT

• REGISTERED NURSE

• RN

• RN LICENSE

Languages:

• English

• Read

• Write

• Speak

Minimum Degree Required:

• Bachelor's Degree

Certifications & Licenses:

• RN

• RN license

• Registered Nurse