Clinical Care Reviewer, Pediatric Shift Care, Registered Nurse

Job Brief

Current, active, and unrestricted RN licensure in PA. 3+ years providing direct patient care as a RN working with medically fragile pediatric patients in a clinical setting. 3+ years of Utilization Management experience, preferably within a MCO.

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:

• Current, active, and unrestricted Registered Nurse licensure in Pennsylvania.
• Proficiency utilizing electronic medical record (EMR) and clinical documentation programs.
• 3+ years of Utilization Management experience, preferably within a managed care organization.
• Experience utilizing evidence based clinical decision support tools, such as InterQual, desired.
• Working knowledge of MS Office including Word, Excel, and Outlook, and Internet applications in Windows 10.
• Graduate from an accredited school of nursing. Bachelor's degree in Nursing preferred.
• Demonstrated ability to prioritize and multi-task to ensure deadlines for deliverables are met.
• Excellent communication, analytical, and critical thinking skills. Detail oriented and strong organizational skills.
• 3+ years providing direct patient care as a Registered Nurse working with medically fragile pediatric patients in a clinical setting.