Job Description

Clinical Care Reviewer

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.

Qualifications

• 3 or more years' experience in a related clinical setting.
• Registered Nurse in Pennsylvania
• 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).

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