**Role Overview:** Use your clinical expertise to make a large impact! Under the direction of the team's supervisor, you will manage requests for pediatric shift care services including skilled nursing and home health aide services, medical daycare, and pediatric residential facilities. You will ;serve as a liaison between the member's family and homecare agencies to ensure the approved services are provided. Our Utilization Management Reviewers cultivate and maintain relationships with our members' caregivers and provide education on the homecare staffing process. They collaborate with our Special Needs/Pediatric Shift Care case management team to ensure continuity of services until they are no longer needed or the member reaches their 21st birthday. ; **Work Arrangement:;** + Remote role. + Monday through Friday from 8:30a EST to 5:00p EST. ; **Responsibilities:** + 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.; + Additionally, based on clinical judgement the Clinical Care Reviewer may contact the home care agency for documentation of member interventions and goals. + 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. Following the shift care workflow the case is presented to the Medical Director for medical necessity review. + maintain current knowledge and understanding of the state contract, policies, and regulations pertaining to Pediatric Shift Care services. ;; ; **Education and Experience:** + Associate's Degree in Nursing required. Bachelor's 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. + Utilization Management experience, preferably within a managed care organization, desired. + Experience utilizing evidence based clinical decision support tools. + 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.; ; **Licensure:;** + Current and unrestricted Registered Nurse license in PA and/or compact state nurse license. ; Your career starts now. We are looking for the next generation of healthcare 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 www.amerihealthcaritas.com. **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. As a company, we support internal diversity through: Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.