Clinical Care Reviewer

Under 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.

• Active unrestricted Pennsylvania RN/LPN license
• 3-5 years’ experience in critical care or ER in an acute environment
• 2 years’ experience in utilization management preferably a managed care environment
• Comfortable using MS Office products (including Excel, Outlook, WORD)

All your information will be kept confidential according to EEO guidelines.