Clinical Care Reviewer

Integrated Resources Inc.; Harrisburg (Dauphin County); On-site; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Care Reviewer to oversee medical necessity reviews. The ideal candidate will possess an active Pennsylvania RN/LPN license with substantial experience in critical care and utilization management. Join a committed team focused on improving patient outcomes while working in a supportive environment.

Qualifications

• 3-5 years’ experience in critical care or ER in an acute environment.
• 2 years’ experience in utilization management preferably in a managed care environment.
• Comfortable using MS Office products.

Responsibilities

• Complete medical necessity reviews using AHC policies.
• Authorize services and refer requests to Medical Director when guidelines are not met.
• Facilitate discharge planning requests.

Skills

Critical thinking

Attention to detail

Communication

Education

Active unrestricted Pennsylvania RN/LPN license

Job description

Integrated Resources, Inc., is led by a seasoned team with combined decades in the industry. We deliver strategic workforce solutions that help you manage your talent and business more efficiently and effectively. Since launching in 1996, IRI has attracted, assembled and retained key employees who are experts in their fields. This has helped us expand into new sectors and steadily grow.

We’ve stayed true to our focus of finding qualified and experienced professionals in our specialty areas. Our partner-employers know that they can rely on us to find the right match between their needs and the abilities of our top-tier candidates. By continually exceeding their expectations, we have built successful ongoing partnerships that help us stay true to our commitments of performance and integrity.

Our team works hard to deliver a tailored approach for each and every client, critical in matching the right employers with the right candidates. We forge partnerships that are meant for the long term and align skills and cultures. At IRI, we know that our success is directly tied to our clients’ success.

Job Description

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.

Qualifications

• 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)

Additional Information

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