Clinical Review Resume Samples

4.7 (112 votes) for Clinical Review Resume Samples

The Guide To Resume Tailoring

Guide the recruiter to the conclusion that you are the best candidate for the clinical review job. It’s actually very simple. Tailor your resume by picking relevant responsibilities from the examples below and then add your accomplishments. This way, you can position yourself in the best way to get hired.

Craft your perfect resume by picking job responsibilities written by professional recruiters

Pick from the thousands of curated job responsibilities used by the leading companies

Tailor your resume & cover letter with wording that best fits for each job you apply

Resume Builder

Create a Resume in Minutes with Professional Resume Templates

Resume Builder
CHOOSE THE BEST TEMPLATE - Choose from 15 Leading Templates. No need to think about design details.
USE PRE-WRITTEN BULLET POINTS - Select from thousands of pre-written bullet points.
SAVE YOUR DOCUMENTS IN PDF FILES - Instantly download in PDF format or share a custom link.

Resume Builder

Create a Resume in Minutes with Professional Resume Templates

Create a Resume in Minutes
DR
D Raynor
Dallas
Raynor
701 Audra Village
Phoenix
AZ
+1 (555) 477 5880
701 Audra Village
Phoenix
AZ
Phone
p +1 (555) 477 5880
Experience Experience
Boston, MA
Clinical Review Assistant
Boston, MA
Weimann Inc
Boston, MA
Clinical Review Assistant
  • Work performed is done in conjuncture with the patient's provider and the care coordinator to complement the office-based clinician's workflow
  • The work performed is to complement the office based clinician's work
  • Participate in regularly scheduled staff development trainings to maintain and improve personal knowledge base of various chronic diseases
  • Assists with clerical duties as assigned i.e. report management, data reports, education material. Completes all documentation per standards/policy
  • Develops and maintains a process to keep staff informed about necessary patient care information
  • Communicate all concerns to clinical team and manager as necessary, seeking support and guidance proactively
  • Provide support and notifies clinical team and manager regarding changes in: Behavior, nutrition, exercise, substance use, medication compliance, and other issues as related to the established care plans. (Within the scope of certification/licensure)
Houston, TX
Clinical Review Auditor
Houston, TX
Welch, Hayes and Schultz
Houston, TX
Clinical Review Auditor
  • Maintains a working mastery of industry-standard utilization review criteria (ie: Interqual), coverage guidelines, and payer medical policies
  • Demonstrates knowledge of governmental, managed care, and commercial denial/appeal policies
  • Notifies department leadership regarding patterns/trends
  • Together works with department leadership and other Denial Management Team Members to develop and facilitate processes which promote job effectiveness and efficiency
  • Actively educates and collaborates with other hospital staff and associates at the SSC regarding denial/appeal strategies
  • Serves as a clinical resource to other associates at the SSC
  • Performance – maintain performance standards that ensure the department is operating at peak proficiency and that established goals are consistently being met
present
Los Angeles, CA
Clinical Review Specialist
Los Angeles, CA
Crooks LLC
present
Los Angeles, CA
Clinical Review Specialist
present
  • Communicate and work effectively with co-workers and Market Leads to coordinate workload to ensure all work is completed daily
  • Communicate to management ways to improve processes and productivity of company
  • Identifies potential data issues and works with PPD team and study sites to resolve. Ensures data accuracy according to departmental operating procedures
  • Knowledge of care management plans and services in order to implement that knowledge in a clinical setting
  • Performs TAR reviews and completion of TAR requests according to Medi Cal format and deadlines
  • Knowledge of care management plans and services in order to implement that knowledge in a clinical in-patient setting
  • Performs on line documentation of clinical justification for hospital stays and pre screening of files to determine if Appeal is warranted
Education Education
Bachelor’s Degree in Nursing
Bachelor’s Degree in Nursing
Central Michigan University
Bachelor’s Degree in Nursing
Skills Skills
  • Knowledge of risk and quality management and patient safety programs and initiatives
  • 1-3 years of risk management and/or patient safety experience
  • Experience with Online Incident Reporting Systems and Microsoft Office suite
  • Active Registered Nurse, Nurse Practitioner, or Physician Assistant license
  • Strong attention to detail
  • Team-oriented
  • Self-motivated
  • Strong organizational skills
  • Excellent written and verbal communication skills
  • Exceptional problem-solving
Create a Resume in Minutes

15 Clinical Review resume templates

1

Supervisor of Clinical Review Resume Examples & Samples

  • RN, BSN
  • Supervisory experience in Medical Management
  • Appeals/Denials experience
  • Medical records experience
  • Knowledge of Medicare and Medicaid Regulations
2

Clinical Review Supervisor Resume Examples & Samples

  • Bachelor's Degree in Nursing or equivalent in education and experience
  • 2+ years of Managed Care experience
  • Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.)
3

Clinical Review Specialist Resume Examples & Samples

  • Knowledge of risk and quality management and patient safety programs and initiatives
  • 1-3 years of risk management and/or patient safety experience
  • Experience with Online Incident Reporting Systems and Microsoft Office suite
  • Active Registered Nurse, Nurse Practitioner, or Physician Assistant license
  • Exceptional problem-solving
  • Coordination and/or management of Online Incident Reporting Systems experience
  • Reproductive health care experience
4

Clinical Review Specialist Resume Examples & Samples

  • Reviews patient data in accordance with the Manual Data Review Plan in the DVM
  • Uses medical knowledge to clarify and resolve issues with clinical data (e.g. adverse events, concomitant medications, concurrent medical conditions etc.) gathered during lifecycle of clinical trials
  • Identifies potential data issues and works with PPD team and study sites to resolve. Ensures data accuracy according to departmental operating procedures
  • Ensures applicable data review activities are conducted accurately, and all related deliverables are completed to quality expectations, within budget and on time. Provides support, guidance and direction on clinical data review to the CDM project team
  • To ensure that all work conducted is completed to the acceptable quality in accordance with SOPs/WPDs, Protocol and DVM
  • To ensure all required documentation, as defined in the SOPs/WPDs and DVM, is created and filed correctly
  • Life Science Degree (and/or relevant qualification/experience)
  • Valid drivers license (where applicable) and passport
  • Ability to effectively apply knowledge and skills in a highly organized fashion utilizing adherence to regulatory guidelines, SOPs and client expectations
  • Knowledge of medical and/or clinical trials terminology
  • Experience that demonstrates strong attention to detail and skill with numbers
  • Good organizational and analytical problem-solving skills
  • Professional ability to deal with individuals from all levels
  • Ability to work in a team environment and independently as required
  • Ability to set and work to timelines and able to effectively negotiate timeline changes if necessity demands
  • Willingness to travel to other locations as required or as business need dictates
  • A minimum of three years relevant experience in a clinical research environment with a minimum of 1 year experience reviewing and validating clinical or medical data. Related experience would be taken into account
  • Knowledge of Oracle Clinical would be an advantage
5

Clinical Review Operations Manager Resume Examples & Samples

  • Manages the operations of the member grievance programs for commercial claims for northern and southern California
  • Conducts internal audits and participates in outside audits by regulatory agencies
  • Manages a staff of approximately 22 people in northern and southern regions
  • Responsible for customer satisfaction by ensuring timely and accurate responses to inquiries and quick resolution of grievance issues
  • Interacts with HP and external regulatory services on at least a weekly basis representing Kaiser Clinical Review in relationship to appeals from members
  • Conducts internal audits to insure compliance with NCQA and DMHC regulations that benefits are applied consistently and within the applicable laws
  • Works with department physicians in identifying areas of risk., needed policy changes, etc
  • Responds to requests from Dept of Managed Health Care for patient specific reviews, providing all available documentation related to decisions made by Health Plan
  • Oversees twice weekly grievance rounds where members may present via phone to appeals committee
  • Minimum five (5) years of progressively responsible experience in the claims/appeals/outside medical services arena
  • Registered nurse a plus, and managing RN's
6

Clinical Review Auditor Resume Examples & Samples

  • 1) Coordinate commercial/managed care audit requests, as assigned
  • 2) Validate and compile audit findings
  • 3) Exit/finalize all completed audits, as requested
  • 4) Draft (in conjunction with a physician reviewer when indicated) medical necessity appeals, as assigned, and
  • 5) Follow-up on all appeals for determinations and additional actions/resolution
7

Clinical Review Operations Manager Resume Examples & Samples

  • Provides leadership and direction for the unit in accordance with the overall strategic direction of the department
  • Serves as the content expert of the responsible area, providing assistance and advice
  • Communicates information effectively, translating financial data into meaningful information that support business decision-making
  • Applies understanding of operational and financial performance to anticipate and meet the needs of clients
  • Holds unit to high standards of performance
  • Assures integrity of data and analysis
  • Defines and frames complex issues and develops time tables/processes for decision making
  • Facilitates the ongoing learning, well-being
  • Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.g, professional satisfaction and development of staff through training, work assignments, increased responsibility/autonomy and mentoring
  • Minimum seven (7) years of directly related financial experience with a variety of projects
  • Experience with SAS and Microsoft access helpful
  • Prior experience managing staff
  • Experience with KP data sources
  • CPA, master's degree, or a minimum five (5) years of experience in the health care industry preferred
8

Clinical Review Operations Senior Manager Resume Examples & Samples

  • Manages the operations of the member grievance programs for commercial claims for northern and Southern California
  • Manages a direct staff of approximately 5-7 people (35 indirect) in Northern and Southern regions
  • Develops goals, objectives, and career paths for staff
  • Hires, trains, and evaluates staff
  • Interacts with Health Plan and external regulatory services on at least a weekly basis representing Kaiser Clinical Review in relationship to appeals from members
  • Provides recommendations and assists director with budget preparation and monitoring
  • Tracks and trends data related to appeal reasons and overturns and reports data to senior management on a quarterly basis
  • Minimum two (2) years in a supervisory capacity
  • Registered Nurse a plus
  • Experience managing in an environment with high production
  • Experience dealing with Federal and State regulators
9

Manager, Hedis Clinical Review Resume Examples & Samples

  • Clinical and/or Health Education experience
  • Minimum of 1 year proven success managing, implementing or auditing quality programs
  • Strong time management and prioritization skills
  • Experience working with international resources for clinical process operations
10

Associate Director, Hedis Clinical Review Resume Examples & Samples

  • Contribute to annual project plan to achieve all HEDIS Clinical Review tasks and objectives
  • Observe and comply with policies and procedures for
  • Minimum 4 year degree or equivalent experience
  • Minimum 3 years Clinical and / or Health Education experience
  • Minimum 4 year Healthcare / Health Plan experience
  • Experience with HEDIS measures
  • RN or LPN
  • Basic statistical knowledge and application of continuous quality improvement concepts, such as Six Sigma or PDCA
11

Clinical Review Assistant Resume Examples & Samples

  • Collects, reviews and documents patient's current health status and history according to standard/policy
  • 100% documented evidence of attendance of staff/department meetings, and/or reading/initializing the minutes, all other memos and postings
  • Is knowledgeable in identifying patients in need of further follow up and refers to the appropriate clinician as indicated. Documents all aspects of the patient management according to hospital and practice standards/policies
  • Understands appropriate interventions that are provided in the clinical setting to include all aspects of the clinical management of the patient
  • Assists Care Coordination/UR staff by researching patient information as assigned
  • Performs ongoing patient screening, and planning through effective collaboration the appropriate clinician
  • Provides telephonic follow-up management of patient per protocol/policy to include but not limited to visits scheduled at time of discharge and Patient/Family notification of next appointment as assigned
  • Organizes and distributes paperwork to all Care Coordination staff in an effective and timely manner
  • Assists with clerical duties as assigned i.e. report management, data reports, education material. Completes all documentation per standards/policy
  • Provides support for activities related to Care Coordination to facilitate on-going communications and efficient departmental operations
  • Coordinates patient educational materials and ensures their availability
  • Provides and distributes all appropriate patient education as directed
  • Documents patient interaction per standard/policy
  • Assume other duties and responsibilities as assigned
  • Coordinates patient education material and follow up as directed
  • Duties are adequately performed as needed or seeks out supervisor for guidelines
  • Performs all other assigned duties as directed by supervisor
  • Maintains certification and BLS certifications. Maintains PPD as needed
  • Demonstrates correct technique in the use of equipment, according to specific product information and policy and procedure manuals
  • Follows appropriate procedure for obtaining and returning/cleansing/disposing of equipment and supplies
  • Accurately researches and compiles assigned statistical data for department in a timely manner. Monthly statistics are completed within the assigned time frame
  • Develops and maintains a process to keep staff informed about necessary patient care information
  • Maintains appropriate departmental records, coordinates mail distribution and establishes departmental filing system to ensure the expeditious retrieval of information so that staff can accomplish their responsibilities
  • Adheres to established organization policies and procedures to include but not limited to HIPAA regulations, Code of Conduct etc., as per EMHS IDD/PCD policies and Beacon Health policies
  • Assure patients get appropriate and timely services by making referrals and motivating / teaching people to seek care
  • Bridge community, cultural, linguistic and educational barriers to encourage self-care and participation in the program
  • Participate in regularly scheduled staff development trainings to maintain and improve personal knowledge base of various chronic diseases
  • Participates and attend regularly scheduled clinic and other assigned meetings
  • Communicate all concerns to clinical team and manager as necessary, seeking support and guidance proactively
  • Complete all required documentation inclusive of electronic documentation, in a timely fashion in accordance with regulations and office standards
  • The work performed is to complement the office based clinician's work
  • All other duties as assigned by regional manager or designee
12

Clinical Review Specialist Resume Examples & Samples

  • Current Registered Nursing License in state of New York required
  • 5+ years of clinical experience in acute care environment
  • Data abstraction Quality Management experience desired
  • Proficiency with relevant computer programs necessary
13

Clinical Review Specialist Resume Examples & Samples

  • Medical background and knowledge of clinical trials terminology
  • Ability to effectively apply knowledge and skills in a highly organized fashion utilizing adherence to regulatory guidelines, procedures and client expectations
  • Experience that demonstrates strong attention to detail and skill with numbersStrong command of English language and grammar
  • 2-3 years of relevant clinical trials or similar experience that demonstrates strong attention to details
  • Proven good organizational and analytical problem-solving skills
  • Ability to work effectively under pressure
14

Hedis Clinical Review Manager Resume Examples & Samples

  • Observe and comply with policies and procedures for assigned scope
  • Minimum 4 year degree
  • Minimum 3 year Healthcare/Health Plan experience
  • Demonstrated ability to assist with focusing activities toward a strategic direction and achieve targets
15

Clinical Review Specialist Resume Examples & Samples

  • Performs TAR reviews and completion of TAR requests according to Medi Cal format and deadlines
  • Performs Medi Cal clinical medical file review of hospital documentation for necessary clinical treatment and patient severity of illness to warrant admissions and continued acute inpatient level of care
  • Performs on line documentation of clinical justification for hospital stays and pre screening of files to determine if Appeal is warranted
  • Conducts clinical review of cases that do not meet criteria
  • Collects and enters confidential information ensuring the highest level of confidentiality in all areas
  • Maintains written documentation according to TOG’S documentation policy
  • Provides ongoing to TAR related to TOG’s Clinical Review process
  • Knowledge of care management plans and services in order to implement that knowledge in a clinical in-patient setting
  • Knowledge of care management plans and services in order to implement that knowledge in a clinical setting
  • Ability to use independent judgment related to medical record review
16

Clinical Review Auditor Resume Examples & Samples

  • Must possess current RN/LPN licensure in state of Florida, Bachelor degree or above preferred
  • Prior experience in denials/appeals preferred
  • At least 3 years of experience as a Case Manager/UR Nurse (any field)
  • At least 3 years of experience in clinical nursing (any field)
17

Manager of Clinical Review Resume Examples & Samples

  • Manage a team of nurses, coders, auditors and other staff in the performance of contract requirements
  • Conduct reviews of medical records and associated pre-pay or post-pay claims in the course of fraud, waste and abuse investigations or carrying out other program integrity initiatives
  • Use knowledge of healthcare coding conventions, fraud schemes, and areas of vulnerability, reimbursement methodologies, and relevant laws to help detect suspicious patterns in claims data, provider enrollment data, and other sources
  • Remain up to date on published fraud cases
  • Perform proactive data analysis and record review by applying knowledge of coding guidelines, medical procedures, medical policies, Medicare / Medicaid policies, etc
  • Demonstrate strong communication skills to prepare superior written investigative summaries for submission to customers' staff and healthcare providers
  • May be the client’s primary point of contact or serve as the lead representing GDHS during customer conversations
  • At least 5 years of supervisory or management experience required
  • Minimum of 8 years of experience in healthcare fraud, waste and abuse reviews (professional, facility)
  • Extensive and thorough knowledge of ICD, CPT, HCPCS, APC, DRG, Revenue Codes, NDCs, and Medicare guidelines (including NCCI)
  • Other certifications a plus: COC, CEMC, AHFI, CHCA, CCS, ART, RHIT, AHFI, CFE
  • Strong proficiency in MS Office suite
  • Experience with STARSSolutions Preferred
  • Healthcare claims adjudication experience
  • Strong knowledge of Medicaid regulations and Medicare coverage determinations
  • Dynamic leader with excellent verbal and written communication skills
  • Strong listening and observation skills
  • Impeccable work ethic, completely dependable, and proactive; a problem solver and thought leader
  • Professional representative of GDIT illustrating polish, integrity, and creating trust
  • Demonstrated ability to provide coaching and performance management of staff
  • Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
  • Presentation skills to communicate with management and customers
  • Willingness to travel approximately 20% of the time
  • Attention to detail and high level of accuracy
  • Demonstrated organizational and prioritization skills with ability to manage multiple priorities effectively
  • Innovative; introduces new ideas and processes that improve performance, productivity and benefit integrity
  • Works independently; collaborates well with peers and customers
18

Clinical Review Operations Supervisor Resume Examples & Samples

  • Responsible for oversight of the daily workflow of emergency claims and ambulance claims in the Clinical Review Department
  • Working under direction of the Clinical Review Manager, assigns work to the Provider Reimbursement Specialists
  • Runs reports during the day to ensure timeliness
  • Reassigns staff to priority tasks
  • Works with the Ambulance Coordinator to assure compliance in the review of ambulance claims
  • Responsible for training new staff, under the direction of the Medical Audit Manager
  • Plans, organizes and distributes work to PRS staff based on compliance timeframes. Runs reports throughout the day to check that work is being completed. Provides feedback to manager to ensure work is in compliance
  • Acts as resource to PRS staff as content expert in reviewing claims for emergency benefit
  • Participates in supervisor meetings with Northern and Southern CCA, HR and Clinical Review
  • Works on special projects that require knowledge of multiple systems
  • Responsible for training new PRS staff to review claims based on routing criteria. Review ICD-9, CPT codes, medical records, UB- 92 and HCFA forms as well as Kaiser Permanente internal systems (OTRS, Advice call logs). Determines if bills are payable or if additional information is needed
  • Works one on one with staff not meeting quality expectations to re-train as needed
  • Communicates daily with Medical Audit Nursing Supervisor and Manager
  • Minimum three (3) years of experience in Clinical Review as Provider Reimbursement Specialist
  • Bachelor's or advanced degree preferred
19

Associate Director, Hedis Clinical Review Resume Examples & Samples

  • Minimum 4 year degree and/or equivalent experience
  • Minimum 4 year Healthcare/Health Plan experience
  • Minimum 2 years of team or organizational leadership experience
  • Prior project management skills
20

Clinical Review Analyst Resume Examples & Samples

  • Evaluate HP work history dates, sites and settings to identify gaps in accuracy and eligibility in order to request necessary information & to assign appropriate skill set on new applications and reapplications
  • Identify process improvement opportunities by evaluating processes and guidelines in order to propose value-added solutions that increase volume, turnaround time and/or accuracy
  • Review convictions, license disciplinary actions, references, PLI (professional liability insurance) history and other derogatory information to determine whether to make a decision on continued eligibility or to escalate to appropriate internal decision makers
  • Processes pre-start cancels, communicates to all stake holders and investigate HPs incurring pre-start cancels to determine eligibility for future assignments; escalating when necessary to Clinical Manager/Director or Clinical Risk Review Committee
  • Prioritize incoming review requests by evaluating business need and urgency in order to increase speed to market
  • Enters, maintains and communicates with team members as appropriate for CLNs with requirement for Medical Release or Work Place Accommodation
  • Generates and manages reports for Clinical Services Department
  • Manages basic Checkster administrative support
  • Reviews and processes returned evaluations and maintains biennial evaluations according to established protocol for updates
  • Education, Certifications & Experience
21

Clinical Review Senior Analyst Resume Examples & Samples

  • Graduation from an accredited school of health information management and four (4) years of relevant experience; or a combination of experience and education
  • Knowledge in medical terminology, anatomy and physiology
  • Three (3) years of experience working in a hospital, medical group, or health plan environment managing clinical review for medical necessity and document integrity; and/or two (2) years in case management experience, clinical documentation improvement, clinical denials management, clinical review
  • Experience with LCDs, NCDs, PEPPER, CERT, QIOs
  • Knowledge of CMS and other payer documentation, compliance, reimbursement and coding requirements
  • Knowledge of federal, state, and local billing and research compliance regulations
  • Ability to assess clinical systems, such as identifying gaps between services required and services available
  • Experience with program evaluation through outcomes measurement, including principles of continuous quality/performance improvement, use of benchmarks and analysis of trends, and other means to create understanding of current condition and return on investment
  • Proficiency in Information Systems, databases, and in the use of technology and computer programs including MS Office (Word, Excel, Power Point, Outlook, etc.)
  • Ability to construct grammatically correct correspondence and reports using standard medical terminology
  • Proven analytical and problem solving skills, ability to problem solve, engage in abstract thought, and successfully manage conflicts. Strong negotiation, organizational, delegation and task prioritization skills
  • Strong communication skills (both verbally and in writing) and proven ability to effectively interact and maintain working relationships with operational, clinical, and financial stakeholders internal and external to the organization
  • Ability to work effectively in a constantly changing environment and maintain a work pace appropriate to the workload, handling multiple tasks and meeting deadlines
  • RN Credential - Bachelor of Science in Nursing (BSN)
  • Knowledge and ability to conduct medical necessity validation reviews
  • Knowledge of DRGs and ICD-9, HCPCS and APC codes
  • Proficient with UCSD Health's computer systems including EPIC E.H.R and other information systems
  • Knowledge of adult learning, instructional design, and curriculum development techniques including use of multimedia / E-Learning learning database systems, with the ability to instruct and conduct training programs and sessions
22

Clinical Review Analyst Resume Examples & Samples

  • Evaluate clinical authorizations for procedural/technical completeness and accuracy
  • Resolve authorization procedural and technical issues with attention to detail and accuracy
  • Query and distribute clinical data reports including but not limited to: open case reports, letter error reports, single case agreement reports, etc
  • Create inquiries into the CareConnect/ServiceConnect application and route to the appropriate clinical department for decision making as necessary
  • Provide professional, accurate and appropriate feedback to management regarding trends and training opportunities
  • Excellent problem solving and analytical skills; strong verbal, written, and interpersonal communication skills
  • Knowledge of Medicaid/HP transmission and claims processes preferred
  • High level of proficiency with Microsoft Office Products (Word, Excel, Outlook, PowerPoint)
23

Clinical Review Specialist Resume Examples & Samples

  • Participation and successful completion of the Clinical Review Specialist training program
  • Review and authorize major dental services based on medical necessity and eligibility, in accordance with contract language
  • Consistently meet Level 1 productivity requirements (16+ authorizations per hour after 6 months)
  • Maintain acceptable audit and IRR scores within departmental guidelines
  • Communicate and work effectively with co-workers and Market Leads to coordinate workload to ensure all work is completed daily
  • Represent DentaQuest in a professional manner at all times
  • Communicate to management ways to improve processes and productivity of company
  • Ability to read and interpret x-rays, dental models, photos, and/or patient charts
  • Efficient PC skills (Word, Excel, Access)
  • Ability to remain organized with multiple interruptions
  • 6 months of dental assisting experience or degree in dental field; previous dental insurance experience
24

Clinical Review Assistant Resume Examples & Samples

  • Assists Care Coordination by researching patient information as assigned
  • Reviews and manages claims reports and other incoming patient information for the purpose of making care coordination referrals and providing patient care within the role and scope of the position
  • Completes auditing reports and queries to ensure the closure of gaps and for the identification of opportunities for improvement
  • Performs all assigned duties as directed by supervisor
  • Ensures duties are adequately performed as needed or seeks out supervisor for guidelines
  • Maintains certification and BLS certifications
  • Demonstrates the ability to develop and build strong computer skills in a variety of software products to include but not limited to EMR documentation and functionality, Microsoft products to include Visio, other products used to support Beacon Health
  • Assure patients get appropriate and timely services by working with the care coordinator and the patient's provider office, by making referral requests as needed and by motivating/teaching people to seek care at the appropriate location and level of care
  • Bridge community, cultural, linguistic and educational barriers to encourage patient self-care and participation in the management of their care
  • Participate and attend regularly scheduled staff meetings and other assigned meetings
  • Work performed is done in conjuncture with the patient's provider and the care coordinator to complement the office-based clinician's workflow
  • Assumes and completes all other duties as assigned by regional manager or designee
25

Clinical Review Auditor Resume Examples & Samples

  • Maintains a working mastery of industry-standard utilization review criteria (ie: Interqual), coverage guidelines, and payer medical policies
  • Demonstrates knowledge of governmental, managed care, and commercial denial/appeal policies
  • Appropriately reviews and triages denials for A/R, billing, downgrade, appeal, or denial adjustment
  • Able to prioritize and manage caseload without jeopardizing timely filing
  • Demonstrates excellent technical and clinical skills by drafting credible, defensible appeals
  • Conducts thorough evidence-based clinical literature research to support appeals, as needed
  • Understands and files appropriate levels of appeal (ie: reconsideration, dispute, appeal, ALJ…)
  • Appropriately utilizes claim and medical informatics for the purposes of developing, tracking, and trending denials and appeals
  • Notifies department leadership regarding patterns/trends
  • Together works with department leadership and other Denial Management Team Members to develop and facilitate processes which promote job effectiveness and efficiency
  • Actively educates and collaborates with other hospital staff and associates at the SSC regarding denial/appeal strategies
  • Serves as a clinical resource to other associates at the SSC
  • Ability to perform all other duties as assigned or requested
  • Communication – communicate clearly and concisely, verbally and in writing; utilize appropriate method/tool to communicate with other departments as necessary
  • Interpersonal skills - able to work effectively with other employees and external parties
  • Policies & Procedures - demonstrate knowledge and understanding of organizational policies, procedures and systems; ensure confidentiality of all patient accounts by following HIPAA guidelines
  • Performance – maintain performance standards that ensure the department is operating at peak proficiency and that established goals are consistently being met
  • Time management and organization - perform work under tight guidelines, must be detail oriented and well organized. Ability to prioritize and control workload
  • Demonstrated critical thinking, creativity, problem solving and decision-making skills
  • To perform this job successfully, an individual should have knowledge of Word Processing software, Spreadsheet software and E-mail software
  • Associate's degree (A. A.). In addition, Bachelor's degree (B.S. or B.A.) from four-year college or University and/or six months to one year related experience and/or training preferred
  • Must possess current LPN licensure in state of Florida