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Clinical Care Reviewer
Ref No.: 18-01557
Location: North Charleston, South Carolina
 
Responsibilities:
  • 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.
 
Required 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.