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AmeriHealth Caritas Clinical Care Reviewer, Appeals, Registered Nurse in Philadelphia, Pennsylvania

Clinical Care Reviewer, Appeals, Registered Nurse

Location: Philadelphia, PA

Telecommuter?: No

ID**: 17497

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:

  • Receives requests for authorization of services, including inpatient hospital admissions, inpatient rehabilitation services, skilled nursing admission, home care, home care infusion services, outpatient and /or inpatient elective surgery, and referrals for physician consultation with nonparticipating physician offices.

  • Demonstrates knowledge and understanding of the laws, regulations and policies that pertain to the organizational unit’s business and conforms with these laws, regulations and policies in carrying out the accountabilities of the job.

  • Maintains a current knowledge NCQA standards and recommendations impacting care assessment, access and delivery including but not limited to, case management, prior authorization, inpatient review, discharge planning, home health and SNF/Rehabilitation services.

  • Conducts review of requested services using established guidelines and standards that are set forth in the UM Policies. To ensure that the level of care; length of stay or services requested are medically appropriate, and the determination is rendered in a timely manner as required by state regulations.

  • Coordinates the discharge planning. Verifies member eligibility prior to authorizing services/care. Ensures appropriate allocation of resources to provide quality patient care in the most cost effective manner

  • Recognizes opportunities for referral and refers appropriately to Care Coordination.

  • Performs Retrospective Review, to ensure that the level of care and length of stay of the patient are medically appropriate, and completed within 30 business days of receipt of necessary review information.

  • Maintains technical proficiency with all support systems and software. –Performs accurate and timely update and closure of authorizations, with appropriate, pertinent documentation.

  • Performs other related duties and projects as assigned.

  • Perform on-site review and off- site activities as business needs are identified.

Education/Experience:

  • Registered Nurse graduated from an accredited program.

  • Current unrestricted Registered Nurse license.

  • Minimum of 3 years nursing experience, in related clinical setting.

  • Managed care or Utilization review experience required.

  • Valid Drivers license and reliable automobile transportation for on-site assignments and off site work related activities.

EOE Minorities/Females/Protected Veterans/Disabled

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