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Lead Clinical Reviewer in Seven Hills, OH at KEPRO

Date Posted: 3/27/2019

Job Snapshot

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Job Description


•         Assures accuracy and timeliness of all applicable review type cases within contract requirements. 

•         Assesses, evaluates and addresses daily work load and queues; adjusts work schedules daily to meet the workload demands of the department.

•         Analyzes productivity of nurse reviewers.

•         Identify nurse reviewers’ orientation and continuous learning needs and in collaboration with the Manager, develops and implements plans to address those identified learning needs.

•         In collaboration with Manager, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas.

•         Maintains current knowledge base related to review processes and clinical practices related to the review processes; functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns.

•         Functions as providers’ liaison and contact/resource person for provider customer service issues and problem resolution.

•         Performs all applicable review types as workload indicates.

•         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.

•         Attends training and scheduled meetings and for maintenance and use of current/updated information for review.

•         Cross trains and perform duties of other contracts within KEPRO to provide a flexible workforce to meet client/customer needs.


•         Education (general level if required) or specific

•         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 or Bachelor’s Degree Program

•         Skills, Knowledge Abilities (SKA)

•         Knowledge of InterQual criteria strongly preferred. 

•         Knowledge of current NCQA/URAC standards strongly preferred

•         Knowledge of the organization of medical records, medical terminology, and disease process required.

•         Strong clinical assessment and critical thinking skills required. Medical record abstracting skills required. 

•         Excellent verbal/written communication skills required.

•         Ability to work in a team environment. 

•         Flexibility and strong organizational skills needed. 

•         Must be proficient in MS Office and internet/web navigation

•         Experience (If needed, describe kind and amount)

•         Minimum 3 years of clinical experience in an acute or med-surgical environment required. 

•         Minimum of 2 year UR and/or Prior Authorization or related clinical 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.

•         Previous workload management experience strongly preferred.

•         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 must have the ability to read and interpret data and complex information and function in a team environment.  In addition, the employee is required to sit for extended periods of time; key and/or control objects; occasionally lift and/or move objects weighing up to 10 pounds; use a personal computer; safely operate an automobile, travel throughout the state, and communicate effectively with internal and external customers.