About the job
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Role Overview:;
Under the direction of a supervisor, the Clinical Care Reviewer – Utilization Management evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Clinical Care Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient’s needs in the least restrictive and most effective manner. The Clinical Care Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making. Productivity expectations include meeting established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment. ;
Work Arrangement:;
- Remote role.
- Availability to work Monday through Friday, 8:00 AM to 5:00 PM, flexible for holidays, occasional overtime, and weekends based on business needs.
Responsibilities:;
- Receive and document notification when member enters the transplant evaluation phase
- Monitor evaluation progress and ensure referrals to INN providers/facilities.
- Ensure timely engagement of case management of all transplant members.
- Conduct utilization management reviews for all transplant services by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines
- Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care.
- Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines.
- Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions.
- Identify and escalate complex cases requiring physician review or additional intervention.
- Ensure compliance with Medicaid industry standards.
- Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment.
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Education & Experience:
- Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred.
- 3+ years of diverse clinical experience in Critical Care, Medical-Surgical, Cardiac, and/or Peri-Operative, Intra-Operative, and Post-Operative care. Experience working with patients through the transplant journey from pre-evaluation to post-transplant care is preferred.
- Proficiency in Electronic Medical Record Systems to efficiently document and assess patient cases.
- Must have utilization management experience in a managed care organization. In-patient prior authorization experience is preferred.;
- Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance.
- Demonstrated ability to pivot between high priority tasks in order to meet productivity standards in a fast-paced, high-volume utilization review environment.
- Ability to gather and critically evaluate clinical information and criterion.
- Current driver’s license required.
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Licensure:
- An active compact state Registered Nurse (RN) license is preferred.
- Must be able to obtain licensure in all markets across the enterprise. ;;
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Your career starts now. We are looking for the next generation of healthcare leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation’s leaders in healthcare 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. We want to connect with you if you’re going to make a difference. Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with over 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.
Our Comprehensive Benefits Package
Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more.