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Pediatric Shift Care Utilization Management Review Nurse, PA

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39280    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. Discover more about us at Responsibilities: 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. ;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. ;; Education/ Experience:

  • Qualified candidates will be able to work Monday through Friday between 8:30a EST and 5:00p EST.;
  • Current, active, and unrestricted Registered Nurse licensure in Pennsylvania.
  • 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.
  • 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.;
Diversity, Equity, and Inclusion At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve. We keep our associates happy so they can focus on keeping our members healthy. 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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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

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