Job Brief

Current and unrestricted RN license in PA required. 3+ yrs NICU exp and exp performing UM reviews.

Responsibilities:

The Clinical Care Reviewer will be scheduled to CORE or FLEX hours to provide access to medical necessity determinations for urgent and contractually required coverage requests on a 24/7, 365 basis.

Under the direction of the supervisor, the Clinical Care Reviewer UM is responsible for completing medical necessity reviews. Using clinical knowledge and experience, the Clinical Care Reviewer UM reviews the 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 Clinical Care Reviewer UM discretion to pend requests for additional information and/or request clarification.

The Clinical Care Reviewer UM will use his/her professional judgment to evaluate the request and ensure that services are appropriately approved, recognize care coordination opportunities and refer those cases to Population Health as needed. The Clinical Care Reviewer UM will apply independent medical judgment to 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 UM will ensure that treatment delivered is appropriate and meets the Member’s needs in the least restrictive, least intrusive manner possible. The Clinical Care Reviewer UM will maintain current knowledge and understanding of and regularly apply the laws, regulations, and policies that pertain to the organizational business units and uses clinical judgment in their application.

This description provides a general overview of the position, recognizing that day to day duties of each individual in the position may vary based on personal experience, skills, supervision, cases and other factors.

Education/Experience:

• Qualified candidates must be able to work a minimum of 4 company recognized holidays per year.
• Associate’s Degree required; Bachelor’s Degree in Nursing preferred.
• Current and unrestricted Pennsylvania Registered Nurse license preferred.
• 3 or more years of experience in a NICU as a Registered Nurse.
• Experience performing utilization management reviews (prior authorization and concurrent reviews), preferably in a managed care organization.
• Proficiency utilizing MS Office and electronic medical record and documentation programs.
• Experience utilizing Interqual desired.
• Strong written and verbal communication skills.
• Ability to think critically to resolve problems.
• Valid Driver’s License and reliable automobile transportation for on-site assignments and off-site work related activities (based on business needs).