Clinical Review Job Description
Clinical review
provides consultation to medical and nursing staff, health information management, and payors on potential issues with reimbursement of hospitalization.
Clinical Review Duties & Responsibilities
To write an effective clinical review job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical review job description templates that you can modify and use.
Sample responsibilities for this position include:
The operation and performance of clinical appeals area
Supervising clinical staff and associated activities in compliance with regulatory accredited requirements
Improving the effectiveness and efficient operations of the Unit
Monitoring case loads and audit charts to ensure documentation meets regulatory and accreditation standards
Monitoring individual case loads and conducts audits of clinical records
Performing corrective action and/or counseling as needed
Completing staff evaluations as needed and other duties assigned
Serve as a medical subject matter expert, and service as a consultant to case managers
Refer clients based on the CRT Physician, thorough medical examination and assessment at an agency affiliated clinic
Establish work limitations/ accommodations (including a need for travel limitations/ accommodations) for all employable clients
Clinical Review Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Clinical Review
List any licenses or certifications required by the position: OASIS, ICD, CPC, NCCPA, LPN, RN, AHFI, BLS, COS, MCG
Education for Clinical Review
Typically a job would require a certain level of education.
Employers hiring for the clinical review job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Master's Degree in Nursing, Education, Health, Medical, Pharmacy, Management, Science, Social Work, Healthcare, Graduate
Skills for Clinical Review
Desired skills for clinical review include:
URAC
NCQA and CMS accreditations
Telephone systems
Medical terminology
Reference materials and documentation that contain market nuances
Coordination of benefits
MS Office and PC skills
Financial aspects of third-party payors and reimbursement
Complaints and grievance guidelines and prescription drug utilization management requirements
CPT
Desired experience for clinical review includes:
Assess temporary disabled clients employability factors
Address all workplace medical emergencies
Provide interventions to optimize health and well-being
Previous experience in managed care utilization management
Experience utilizing InterQual, Milliman Care Guidelines, or CMS guidelines
Comprehensive knowledge of all Microsoft Office applications, including Outlook Word, and Excel
Clinical Review Examples
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Clinical Review Job Description
Job Description Example
Our company is growing rapidly and is hiring for a clinical review. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for clinical review
- Educate employees on changing information while improving the quality and effectiveness of documentation being submitted
- Assist with gathering data for routine reporting with other team members
- Act as a liaison between Field Nurses and Nurse Supervisors to improve clinical processes and work-flow communication
- Uses medical knowledge to clarify and resolve issues with clinical data
- Develop and maintain C&S pend management policies and procedures annually in collaboration with appropriate stakeholders
- Develop and maintain C&S Rate Maximization policies and procedures annually in collaboration with appropriate stakeholders
- Support C&S Health Plans to conduct pend resolution for states requesting support during annual retrospective HEDIS hybrid process
- Is knowledgeable in identifying patients in need of further follow up and refers to the appropriate clinician as indicated
- Assists with clerical duties as assigned report management, data reports, education material
- Accurately researches and compiles assigned statistical data for department in a timely manner
Qualifications for clinical review
- New York State ANP or FNP
- Active RN License in the state that you reside
- 3 years of prior clinical experience
- Basic Microsoft Excel and Word experience
- Health Plan/Insurance experience
- Graduate of an accredited School of Pharmacy with a Bachelors or PharmD degree
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Clinical Review Job Description
Job Description Example
Our company is looking to fill the role of clinical review. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical review
- Facilitation of case reviews, presentations and team review meetings
- Data collection and analysis within systems
- Excellent written documentation and record keeping
- Ability to professionally interact with various levels of leadership and teams within OADS
- Coordinates with other Care Managers and CRL Clinical Leadership to assure that patient comprehensive treatment needs are met
- Provides consultation to workplace on issues related to troubled employees, substance abuse cases, management referral, regulatory referrals, onsite training and debriefing services
- Work with all assigned branches to assure accurate ICD-9 (10) and OASIS coding
- Work with regional and divisional management to develop and implement best practices for documentation and coding of Homecare and Hospice services
- Collaborate with all management teams to develop clinical strategies
- Keep abreast of pertinent industry utilization, Medical coding practice standards and guidelines for both payers providers and ensures all applicable processes are in alignment with company process and standards
Qualifications for clinical review
- Home Health experienced preferred
- 5+ years dental managed care experience with specific exposure to claim review and utilization management
- Basic skills in Microsoft office, including Excel
- Able to apply principles of quality improvement to workflows
- Experience using CGX, CCA, MTV, CAS, MACESS, or CCP2
- Excellent skills in complex analytic problem solving, project management and group processes
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Clinical Review Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of clinical review. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical review
- Participate in the development of company UR guidelines and protocols
- Review OASIS, assessment documents and Medical coding at individual branch locations to ensure consistent application and follow through
- Prepare and provide reporting on branch coding
- Keep abreast of pertinent industry utilization, Medical and OASIS coding practice standards and guidelines for both payers providers and ensure all applicable processes are in alignment with company process and standards
- Participate in educating branch and regional staff in best documentation practices and protocols of care that drive both excellent clinical outcomes ensuring accurate financial reimbursement for services provided
- Maintains individual productivity and performance standard, the telephone service standards with are in effect at the time
- Work with all assigned locations to assure accurate ICD-10 coding
- Perform patient chart reviews for clinical study through ORCA/MINDscape
- Determine eligibility and extract appropriate data from chart
- Coordinates with other Care Managers and Commercial Referral Line Clinical Leadership to assure that patient comprehensive treatment needs are met
Qualifications for clinical review
- Knowledge and understanding of call center metrics
- Proficient with computers and using multiple applications simultaneously
- Mail order Pharmacy experience or experience working with PBM
- Background in medical or pharmacy insurance
- Master’s or Bachelor’s degree in a field related to health or emergency medical service, or an equivalent combination of education and career experience
- Preference given to Master’s Level degree
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Clinical Review Job Description
Job Description Example
Our company is hiring for a clinical review. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical review
- Manages a team of clinicians serving Care Services markets and product lines who conduct clinical reviews of new enrollees
- Oversees activities, resolves problems and provides guidance to team members
- Provides effective orientation to systems, tools, chart review processes and reporting
- Ensures ongoing development of clinical staff
- Evaluates performance of team members through regularly scheduled audits of work products to ensure comprehensive patient assessments and clinical accuracy of 95% for each reviewer
- Care Mangers are responsible for submitting all LOC requests that may not meet MNC to a PerformCare PA for review and final determination of approval or denial of care
- Assist with basic processing of lab specimens and associated record keeping
- Maintaining pended claims, electronic inquiries and medical records work queue in order to review assigned claims
- Preparation of claims for medical director review through completion of worksheets and provision of all pertinent medical information
- Meeting company/department standards for timeliness of review and release of claims, and for the accuracy of medical decisions
Qualifications for clinical review
- Current Professional Licensure as RN
- Three years minimum work experience with IDD/ASD fields
- Preference given to DDNA Certification for work with IDD/ASD populations
- Experience – Responsibility and minimum number of years - 8+ Years in drug development, preferably with experience in a clinical data review role
- Software that must be used independently and without assistance (e.g., Microsoft Suite) - Basic office tools
- Current ICD-9 (10) coding certification preferred
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Clinical Review Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of clinical review. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical review
- Performing all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines
- Review forms and documents for version control and against minimum submission criteria for initial submissions, continuation review, and modifications, with strong attention to detail
- Detect inconsistencies in study document versions, accrual, study status, and obtain explanations and/or corrections from study staff across multiple IRBs and committee reviews
- Ensure new protocol submissions follow the correct submission process for the type of study submitted
- Able to review between 15 to 25 new submissions per week in addition to maintaining ongoing submissions
- Must be able to confirm accurate documents are available to study teams with minimal error rates
- Work with Committee Coordinators to ensure all initial submissions, modifications, and annual renewals receive appropriate Data Safety Monitoring and Scientific Reviews
- Provide practical guidance on Clinical Research Support procedures when possible and research questions to provide an appropriate answer, contact person, or documentation to study staff
- Collaborate with the Protocol Review Coordinator team to improve processes and procedures
- PRCs must understand and adhere to local Consortium policies, SOPs, and regulations relevant to the position
Qualifications for clinical review
- Current OASIS C Certification and ICD-9 (10) coding certification preferred
- Strong written and verbal communication skills in both, English & Spanish - Candidate selected will not be communicating with External Clients, Members or Providers in English
- Perform proactive data analysis and record review by applying knowledge of coding guidelines, medical procedures, medical policies, Medicare / Medicaid policies
- Bachelor’s degree and/or Certified Professional Code-CPC-H preferred
- Previous (3-5 years) clinical experience
- Ability to use standard office equipment related to job responsibilities, including computer, fax machine, photocopier, and calculator