AmeriHealth Caritas Clinical Care Reviewer UM in Harrisburg, Pennsylvania
Clinical Care Reviewer UM
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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 of Utilization Management, the Clinical Care Reviewer is responsible for completing medical necessity reviews using AHC policies and procedures. Consistently applies medical health benefit policy and medical management guidelines to authorize services. Identifies and refers requests for services to the appropriate Medical Director when guidelines are not met. Reviews inpatient and outpatient services requiring Plan approval; reviews may be pre-service, concurrent or retrospective in nature. Assesses and appropriately channels/facilitates discharge planning requests.
- Receives requests for authorization of services, including inpatient hospital admissions, inpatient rehabilitation services, skilled nursing admissions, home care /home infusion services, outpatient and/or inpatient services including, but not limited to, elective surgery, and referrals for specialty physician consultation with non-participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).
- Verifies and documents member eligibility for services.
- Communicates and interacts in a real time basis via “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process (es)
- Utilize technology and resources (computer-based systems, telephones, etc.) to appropriately support work activities. Voice mail is an adjunct to the daily work activities versus major reliance for giving and receiving information from providers; accessing and applying medical guidelines for decision making prior to Medical Director/Physician Advisor referral.
- Applies AHC authorization process (InterQual Medical Guidelines, Milliman USA, process standards, policies and procedures, and standard operating procedures) to submitted information. Authorizes services in accordance with medical and health guidelines.
- Coordinates with the referral source if insufficient information is not available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows AHC process for requesting additional information.
- Refers cases to AHC Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.
- Documents case activities for Utilization determinations and discharge planning in a real time manner (as events occur). Completes detail lines as indicated.
- Provides verbal/fax denial notification to the requesting provider and member as per policy. Generates denial letters in a timely manner.
- Adheres to process standards, standard operating procedures, and policies and procedures as defined by specific UM roles (Prior Authorization, Concurrent Review).
- Submits appropriate documentation/clinical information to clerical support for record keeping and documentation requirements.
- Recognizes opportunities for referrals to Integrated Care Management Department and refers accordingly.
- Participates in quality reviews and inter-rater reliability processes and achieves performance results at or above thresholds established by management.
- Maintains awareness and complies with AHC authorization timeliness standards based on DPW/DHS, NCQA, and CMS requirements.
- Performs other related duties and projects as assigned.
- Obtains necessary professional and continuing education required for licensure and any applicable certifications.
- Complies with AHC and HIPAA confidentiality requirements and ensures protection of member personal identifiable health information.
- Perform on-site review and off-site activities as business needs are identified.
- Registered Nurse, graduated from an accredited Diploma, Associates Degree or Bachelor’s Degree program.
- Minimum of 3 years nursing experience, in related clinical setting.
- Managed care experience required with focus on Medicaid population preferred.
- Current Unrestricted Pennsylvania Registered Nurse License required.
- Valid Drivers license and reliable automobile transportation for on-site assignments and off-site work related activities.
EOE Minorities/Females/Protected Veterans/Disabled