This individual will be responsible for one or more types of medical record medical necessity clinical reviews. Clinical reviews may be (1) inpatient or outpatient, (2) for any payer type and (3) may be concurrent, pre-bill or retrospective based on the client service provided. Examples work activities include and are not limited to: Clinical Pre-certifications, Utilization Reviews, Clinical Appeals, and Patient Status Reviews. This role requires strong communication skills both verbal and written as well as expertise in applying medical necessity criteria, doing research on current clinical practices and rules/regulations, and data analyses for the purpose of identifying for the client areas of performance improvement opportunity. The Clinical Review Clinician will be working directly with clients; managing their accounts and relationships effectively.
Essential Duties and Responsibilities:
Knowledge, Skills, Abilities:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Include minimum education, technical training, and/or experience required to perform the job.
The above statements describe the general nature and level of work being performed as of the date of preparation and approval. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of the position. Employees holding this position will be required to perform any other job-related duties as requested by management. The job description does not constitute an employment agreement between the employer and employee, and all requirements are subject to possible modification to reasonably accommodate individuals with disabilities.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.