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Clinical Reviewer in Bloomington, MN at KEPRO

Date Posted: 11/7/2018

Job Snapshot

  • Employee Type:
    Full-Time
  • Job Type:
  • Experience:
    At least 3 year(s)
  • Date Posted:
    11/7/2018

Job Description

Clinical Reviewer

Summary Description

Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.

Accountabilities
• Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
• Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
• Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties.
• Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.
• Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
• Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
• Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
• Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following KEPRO policies, procedures and guidelines
• Actively cross-trains to perform duties of other contracts within the KEPRO network to provide a flexible workforce to meet client/consumer needs.

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

Qualifications

• Education (general level if required) or specific courses
• Active unrestricted LPN, RN, Social Worker or other applicable State and/or Compact State clinical license per contract requirements.
• Graduation from an accredited Diploma, Associates Degree or Bachelor’s Degree Program

Knowledge, Skills, Abilities

• Knowledge of InterQual criteria strongly preferred.
• Knowledge of current NCQA/URAC standards strongly preferred
• Medical record abstracting skills required.
• Knowledge of the organization of medical records, medical terminology, and disease process required.
• Strong clinical assessment and critical thinking skills required.
• Excellent verbal and written communication skills required.
• Ability to work in a team environment.
• Flexibility and strong organizational skills needed.
• Must be proficient in Microsoft Office and internet/web navigation

Experience
• Minimum two years of clinical experience in an acute or med-surgical environment required.
• Minimum of one year UR and/or Prior Authorization or related experience.
• For BH Programs: Minimum 3 years direct behavioral/mental health experience in a clinical setting or other applicable State and/or Compact State clinical experience or license per contract requirements.

Mental and Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

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