AmeriHealth Caritas *Clinical Care Reviewer - Behavioral Health Utilization Management Review in Baton Rouge, Louisiana
*Clinical Care Reviewer - Behavioral Health Utilization Management Review
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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 .
Under the direction of the Supervisor, the Clinical Care Reviewer (CCR) is responsible for completing medical necessity reviews. Using clinical knowledge and experience, the clinician 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 Clinical Care Reviewer’s discretion to retain requests for additional information and/or request clarification. The CCR 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 to integrated care management as needed. The incumbent applies medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated. The Clinical Care Reviewer will ensure that treatment delivered is appropriately utilized and meets the Member’s needs in the least restrictive, least intrusive manner possible. The incumbent 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.
- Requires a graduate degree from an accredited educational program in Social Work, Clinical/Counseling Psychology, or Nursing
- Demonstrated knowledge of plan benefit information and managed care
- Requires licensure for RN, LCSW, LSW, LPC, LMFT.
- Minimum three (3) years post graduate clinical experience or equivalent combination of education and clinically related work experience
- Minimum one (1) year experience working with a managed care system
- Minimum one (1) year experience in behavioral health service delivery system
- Knowledge base in Medicaid, Medicare and commercial managed care systems
- PC skills and experience utilizing Microsoft Office, Outlook, Excel and PowerPoint
- Ability to provide constructive feedback with a focus on improved quality
- Ability to communicate in a positive/professional manner both verbally and written
- Ability to work independently, complete multiple tasks in the allotted timeframe
- Strong problem solving skills and decision making skills
- Ability to work effectively in a team environment
EOE Minorities/Females/Protected Veterans/Disabled