Clinical Care Reviewer

Clinical Care ReviewerUnder 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)All your information will be kept confidential according to EEO guidelines.