Clinical Care Reviewer Utilization Management

AmeriHealth Caritas
August 4, 2022
United States
Job Type
Work Setting


The Clinical Care Reviewer is supervised by a UM 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.


  • Associate’s Degree.
  • Bachelor’s Degree preferred.
  • Registered Nurse graduated from an accredited program.
  • Current unrestricted 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.


Drop files here browse files ...
Resume, cover letter, or other documents as required per the job description

Related Jobs

HIM Manager   Edwards, CO new
August 11, 2022
Chief Medical Officer   Soldotna, AK new
August 11, 2022
Medical Writer, Training   United States new
August 11, 2022
Mental Health Clinician   San Diego, CA new
August 11, 2022
Are you sure you want to delete this file?