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clinical care reviewer - UM (Non-Member Facing)
Ref No.: 18-12749
Location: Philadelphia, Pennsylvania
Start Date / End Date: 10/09/2018 to 03/26/2019
Rec ID: 8628714
Job Title: Clinical Care Reviewer - UM
Location: Philadelphia, PA 19113
Duration: 6 Months

  • ¿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 pend 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.
  • Excellent oral and written communication skills.
  • Ability to identify problems and recommend solutions.
  • Self-directed/Ability to work independently. Excellent decision making skills.
  • Excellent time management skills, prioritizing work and meeting timelines.
  • Ability to advocate for member/member family needs.
  • Dedicated to meeting the expectations and requirements of internal and external customers.
  • Obtains continuing education required to maintain professional licensure.
  • Ability to achieve required performance results on all audits and Inter Rater Reliability (Peer to Peer). Physical Effort/Working Conditions
  • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.
  • Primarily works in a climate controlled office based setting.
  • Skills: Registered Nurse
  • Current state unrestricted RN license.
  • 3 or more years' experience in a related clinical setting.

  • Registered Nurse graduated from an accredited program
  • BSN

Required Skills:

Additional Skills:
  • RN
  • LPN