Clinical Care Reviewer

Clinical Care ReviewerIntegrated Resources, Inc., is led by a seasoned team with combined decades in the industry. We deliver strategic workforce solutions that help you manage your talent and business more efficiently and effectively. Since launching in 1996, IRI has attracted, assembled and retained key employees who are experts in their fields. This has helped us expand into new sectors and steadily grow.We've stayed true to our focus of finding qualified and experienced professionals in our specialty areas. Our partner-employers know that they can rely on us to find the right match between their needs and the abilities of our top-tier candidates. By continually exceeding their expectations, we have built successful ongoing partnerships that help us stay true to our commitments of performance and integrity.Our team works hard to deliver a tailored approach for each and every client, critical in matching the right employers with the right candidates. We forge partnerships that are meant for the long term and align skills and cultures. At IRI, we know that our success is directly tied to our clients' success.Job DescriptionUnder 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.QualificationsActive unrestricted Pennsylvania RN/LPN license3-5 years' experience in critical care or ER in an acute environment2 years' experience in utilization management preferably a managed care environmentComfortable using MS Office products (including Excel, Outlook, WORD)