Clinical Review Specialist

SUMMARY:

This position is responsible for maintaining proper clinical review and interpretation of medical records and claim documentation to assist with the appeals of denied insurance claims including drafting appeal letters based on clinical judgment and knowledge.

DUTIES AND RESPONSIBILITIES:

• Utilizes TimeMatters to obtain work assignments and communicates claim notes in a clear, concise manner.

• Examines and interprets medical records and claim documentation (such as EOBs and UB-04s) to appeal denied insurance claims for inpatient and outpatient services.

• Applies clinical judgment and knowledge for medical necessity, admission, and other clinical reviews.

• Drafts, reviews, and revises appeal letters, including from other staff.

• Confirms that the correct letter format, guidelines, and argument were used.

• Confirms letters are logical and easy to comprehend.

• Ensures all necessary attachments are noted and included with appeal.

• Confirms the page number citations correspond with the medical record.

• Turns around high dollar and/or short deadline cases in a timely manner.

• Sends all appeals, follows-ups, and other forms of documentation within timely filing periods.

• Abides by all HIPAA and other compliance rules and regulations.

• Assists with development of clinical training materials for other staff.

• Assists with clinical training of other staff.

• Performs other related duties as assigned by management.

QUALIFICATIONS:

• Bachelor's Degree (BA) from four-year college or university, or one to two years of related experience and/or training, or equivalent combination of education and experience.

• Certificates, licenses and registrations required:

• licensed as a Registered Nurse (including RN, APRN, CRNP), Nurse Practitioner (including CNP, LNP, NPC), Physician Assistant, Physician, or other qualified healthcare provider.

• Other skills required:

• Knowledge in health, knowledge of current practices and documentation requirements regarding the care and treatment of the population served.

• Knowledgeable of HIPAA.

• Knowledge of administrative and data systems, procedures and processes for improving program effectiveness and efficiency.

• Knowledge of data collection, compilation, and reporting.

• Ability to prepare clear and concise reports.

• Ability to train, consult, and present improvement recommendations to staff, committees, and others.

• Ability to evaluate and analyze systems problems and make recommendations for corrective actions.

COMPETENCIES:

• Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.
• Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.
• Business Necessity - The needs of the employer may be dependent on responding to and anticipating rapidly changing external and internal demands in all aspects of how business is conducted. This may include, but is not limited to, organization structure, finances, goals, personnel, work processes, technology, and customer demands. Therefore, it may become necessary to make modifications to how business is conducted, and work is accomplished, with minimal or no advance notice to employees. Accordingly the employee must be capable of adapting, with minimal or no advance notice, to changes in how business is conducted, and work is accomplished, with no diminishment in work performance.
• Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
• Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals; Completes tasks on time or notifies appropriate person with an alternate plan.
• Diversity - Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; Educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce.
• Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
• External Working Relationships - Develops and maintains courteous and effective working relationships with clients, vendors and/or any other representatives of external organizations.
• Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Judgement - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
• Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
• Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
• Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
• Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.
• Strategic Thinking - Develops strategies to achieve organizational goals; Understands organization's strengths & weaknesses; Analyzes market and competition; Identifies external threats and opportunities; Adapts strategy to changing conditions.
• Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.