Job Description

Role Overview

Under the direction of the unit Supervisor, the Clinical Care Reviewer- Shift Care is responsible for managing requests for pediatric shift care services including skilled nursing and home health aide services, medical daycare, and pediatric residential facilities. Upon receipt of a request from a physician for shift care services, the Clinical Care Reviewer contacts the parent/guardian to complete a comprehensive assessment of the member’s medical, behavioral, and social needs.;

Responsibilities

• Using clinical knowledge and professional judgement, the Clinical Care Reviewer obtains additional information regarding the member and family to support the medical necessity of the requested services
• The Clinical Care Reviewer may contact the physician to discuss and/or clarify the hours or services requested and may ask for additional supporting documentation when needed. Additionally, based on clinical judgement the Clinical Care Reviewer may contact the home care agency for documentation of member interventions and goals
• Following the shift care workflow the case is presented to the Medical Director for medical necessity review. Upon approval of services, responsibilities include timely notification and education to the parent/guardian regarding home care staffing process
• The Clinical Care Reviewer coordinates with the family and home care agency to ensure approved services are provided. The Clinical Care Reviewer refers the member to a Special Needs/Pediatric Shift Care Case Manager and works collaboratively with that Case Manager to ensure the continuation of the services until they are no longer needed or until the member’s 21st birthday
• The nurse will maintain current knowledge and understanding of the state contract, policies, and regulations pertaining to Pediatric Shift Care services

Work Arrangement;

• Remote
• Qualified candidates will be able to work Monday through Friday between 8:30a EST and 5:00p EST

Education and Experience:

• Associate Degree in Nursing. Bachelor Degree in Nursing preferred
• Minimum of 3 years of experience providing direct patient care;as a Registered Nurse working with medically fragile pediatric patients in a clinical setting
• Minimum of 3 years of Utilization Management experience, preferably within a managed care organization
• Experience utilizing evidence based clinical decision support tools, such as;InterQual, desired

Licensure

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

Skills & Abilities

• 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, Outlook, Teams, and Internet applications in a Windows based environment
• Proficiency utilizing electronic medical record (EMR) and clinical documentation programs

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

At AmeriHealth Caritas, we are 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 would like to connect with you.

Headquartered in Newtown Square, Pennsylvania, 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.

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Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

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