Clinical Care Reviewer

Clinical Care Reviewer

Under the direction of the unit supervisor, the clinical care reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse 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 nurse's discretion to pending requests for additional information and/or request clarification. The nurse 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 as needed. The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the medical director when guidelines are not met. The nurse 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.

Qualifications

• Current, unrestricted SC registered nurse license.
• 3+ years' experience in critical care or ER within an acute care environment.
• 2+ years' experience in utilization management, preferably within managed care.
• Comfortable utilizing MS Office products, including Excel, Word, and Outlook.