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Clinical Reviewer in Harrisburg, PA at KEPRO

Date Posted: 12/20/2017

Job Snapshot

Job Description



JOB TITLE:            NurseReviewer

REPORTS TO:      SupervisorReview Operations

DEPARTMENT:  ReviewOperations Department

FLSA STATUS:     Nonexempt

Summary Description

Responsibilities include review of medical records utilizingappropriate criteria in conjunction with critical thinking and decision makingskills to determine medical appropriateness, while maintaining production goalsand QA standards.  



  • Reviews and interprets patient records andcompares against criteria to determine medical necessity and appropriateness ofcare; determines if the plan of care is followed in a timely manner and thatthe medical record documentation supports the delivery of quality care. 
  • Determines approval or initiates a referral tothe physician consultant and processes physician consultant decisions ensuringreason for the denial is described in sufficient detail on correspondence.
  • Abstracts review related data/informationaccurately and timely on appropriate review tool by the appropriate means.  Accurate and timely submission of alladministrative and review related documents to appropriate parties.
  • Ongoing reassessment of review process to offeropportunity for improvement and/or change. 
  • Foster positive and professional relationshipsand act as liaison with internal and external customers to ensure effectiveworking relationships and team building in order to facilitate the reviewprocess.
  • Responsible for attending training and scheduledmeetings and for maintenance and use of current/updated information for review.
  • Maintains medical records confidentiality at alltimes through proper use of computer passwords, maintenance of secured files,adherence to HIPAA polices. 
  • Utilizes proper telephone etiquette andjudicious use of other verbal and written communications, following KePROpolicies, procedures and guidelines
  • Cross-trains to perform duties of othercontracts within the KePRO network to provide a flexible workforce to meetclient/consumer needs.

The list of accountabilities is not intended to beall-inclusive and may be expanded to include other duties that management maydeem necessary from time to time


  • Education (general level if required) orspecific courses         
  • Active unrestricted LPN/RN licensure required.
  • Graduate from an accredited School of Nursing orcollege.   

Skills, KnowledgeAbilities (SKA)

  • Knowledge of InterQual criteria preferred. 
  • Good verbal and written communication skillsessential.
  • Strong critical thinking skills necessary.
  • Ability to work in a team environment. 
  • Flexibility and good organizational skillsneeded. 
  • Medical record abstracting skills required. 
  • Knowledge of the organization of medicalrecords, medical terminology, disease process required.


  • Two years of clinical nursing in an acute healthcare environment required. 
  • Minimum of one year UR, QA, Case Management orrelated experience.
  • Basic computer skills (copy/cut, paste,maneuvering screens and typing) necessary. 

Mental and PhysicalRequirements


The physical demands described here are representative ofthose that must be met by an employee to successfully perform the essentialfunctions of this job.  Reasonableaccommodations will be made as required by law in an attempt to enable anindividual with a disability to perform the essential functions of this job.While performing the duties of this job, the employee is regularly required tosit for prolonged periods of time; key and/or control objects; interactextensively with internal and external customers; occasionally lift and/or moveobjects weighing up to 10 pounds; and occasionally travel within the state.

EOE AA M/F/Vet/Disability


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