* 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 send 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. May require driving or commuting to health care facilities. Some positions may require a large amount of walking within the health care facility.
* Registered Nurse or LPN
* Current unrestricted PA Practical Nurse license or PA Registered Nurse license.
* Valid Driver's License and reliable automobile transportation for on-site assignments and off-site work related activities
* 3 or more years* experience in a related clinical setting.
* Licensed Practical Nurse or Registered Nurse graduated from an accredited program Skills.
* Medical Management
* Registered Nurse