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AmeriHealth Caritas Clinical Care Reviewer, UM, Registered Nurse, REMOTE in Remote, United States

Clinical Care Reviewer, UM, Registered Nurse, REMOTE

Location: Remote, United States

Primary Job Function: Medical Management

ID**: 24815

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at .

The Clinical Care Reviewer is supervised by a Utilization Management Supervisor and is responsible for evaluating a member’s clinical condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for inpatient and outpatient services based on independent analysis of those medical records and application of appropriate medical necessity criteria. The Clinical Care Reviewer is empowered to bind the company financially by independently authorizing services determined to be medically necessary based on the independent review and to refer and consult with a medical director for those services that do not meet medical necessity criteria. Clinical Care Reviewers directly interact with providers to obtain additional clinical information and participate in the development and modification of medical necessity criteria and policies for the company and its customers, as well as assisting management with development of short- and long-term business objectives. Throughout the performance of their duties, Clinical Care Reviewers provide a front-line regulatory/compliance function in their evaluation and application of the criteria. Clinical Care Reviewers are supported by administrative staff responsible for compiling information, data entry and other tasks to build cases and facilitate their work so that Clinical Care Reviewers can focus the majority of their time on applying their medical knowledge to medical necessity reviews. This job description is intended to provide a general overview of the position, while recognizing that actual day-to-day duties may vary among Clinical Care Reviewers depending on, as a few examples, their education, experience, skills, supervisor, and caseload.

  • Receives requests for authorization of services, including inpatient hospital admissions, inpatient rehabilitation services, Skilled Nursing admission), home care home infusion services, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non-participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).

  • Verifies and documents member eligibility for services.

  • Communicates and interacts in a real time bases via “live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).

  • Utilizes technology and resources (systems, telephones, etc.) to appropriately support work activities. Applies Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.

  • Applies submitted information to Plan authorization process (utilizing Milliman, USA, Interqual medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.

  • Coordinates with the referral source if insufficient information is not available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows Plan process for requesting additional information.

  • Refers cases to Plan Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.

  • Documents case activities for Utilization determinations and discharge planning in MeDecision in a real time manner (as events occur). Completes detail line as indicated. Completes ASF per policy.

  • Provides verbal/fax denial notification to the requesting provider as per policy. Generates denial letter in a timely manner.

  • Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)

  • Submits appropriate documentation/clinical information to clerical support for record keeping and documentation requirements.

  • Recognizes opportunities for referrals to Care Coordination Department, and refers accordingly.

  • Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.

  • Maintains awareness and complies with Plan authorization timeliness standards based on DPW/NCQ requirements.


  • Graduate from an accredited school of nursing. Bachelor's degree in Nursing preferred.

  • Current, active, and unrestricted Registered Nurse licensure in Pennsylvania.

  • 3+ years providing direct patient care as a Registered Nurse in a related clinical setting.

  • 3 years of Prior Authorization/Utilization Management experience, preferably within a managed care organization (Medicaid/Medicare/Exchange).

  • Experience utilizing evidence based clinical decision support tools, such as InterQual, desired.

  • Excellent communication, analytical, and critical thinking skills. Detail oriented and strong organizational skills.

  • Demonstrated ability to prioritize and multi-task to ensure deadlines for deliverables are met.

  • Working knowledge of MS Office including Word, Excel, and Outlook, and Internet applications in Windows 10.

  • Proficiency utilizing electronic medical record (EMR) and clinical documentation programs.

  • Valid Driver’s License and reliable automobile transportation for on-site assignments and off-site work related activities

  • This position may require some weekends/holidays.

EOE Minorities/Females/Protected Veterans/Disabled