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Clinical Reviewer in Scarborough, ME at KEPRO

Date Posted: 2/17/2018

Job Snapshot

Job Description



JOB TITLE:            ClinicalReviewer

REPORTS TO:      SupervisorReview Operations

DEPARTMENT:  ReviewOperations Department

FLSA STATUS:     (  ) Exempt                          (X)Nonexempt

Summary Description

Utilizes clinical expertise for the review of medicalrecords against appropriate criteria in conjunction with contract requirements,critical thinking and decision making skills to determine medicalappropriateness, while maintaining production goals and QA standards. Ensuresday-to-day processes are conducted in accordance with regulatory standards.


  • Reviews and interprets patient records andcompares against criteria to determine medical necessity and appropriateness ofcare; determines if the medical record documentation supports the need forservices. 
  • 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 all administrative and review relateddocuments to appropriate parties.
  • Performs ongoing reassessment of review processto offer opportunities 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
  • Actively 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, Social Worker orother applicable State and/or Compact State     clinical license per contract requirements.
  • Graduation from an accredited Diploma,Associates Degree or Bachelor’s Degree Program
  • Social Workers must have a Master’s Degree andcurrent unrestricted Clinical License.
  • Knowledge, Skills, Abilities (KSA)
  • Medical record abstracting skills required. 
  • Knowledge of the organization of medicalrecords, medical terminology, and disease process required.
  • Strong clinical assessment and critical thinkingskills required.
  • Excellent verbal and written communicationskills required.
  • Ability to work in a team environment. 
  • Flexibility and strong organizational skillsneeded. 
  • Must be proficient in Microsoft Office andinternet/web navigation
  • Knowledge of InterQual criteria preferred. 
  • Knowledge of current NCQA/URAC standardspreferred


  • Minimum two years of clinical experience in arelated environment required. 
  • Minimum of one year UR and/or PriorAuthorization or related experience.
  • For BH Programs: Minimum 2 years direct behavioral/mental health experience in a clinicalsetting or other applicable State and/or Compact State clinical experience orlicense per contract requirements.

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 AAM/F/Vet/Disability


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