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Clinical Reviewer III in Jacksonville, FL at One Call

Date Posted: 4/16/2018

Job Snapshot

Job Description

Clinical Reviewer III

Responsible for completing clinical QA audits and/or plan of treatment reviews specific to their licensure and scope of practice. Reviews to provide recommendations related to the medical necessity for ongoing care, progression of treatment, appropriateness of past treatments, and billing accuracy. The Clinical Reviewer’s primary stakeholder is the client (Adjuster/NCM) and must ensure their review/explanation assists and does not hinder the client from making the best decision on how to proceed with the file regardless of their opinions on the treatment that should be performed. Also responsible for providing clinical expertise and collaboration on other One Call processes and customer issue resolutions.

GENERAL DUTIES & RESPONSIBILITIES:

•Review Evaluations, plan of treatments, progress notes, and other clinical documentation and provide a report of clinical guidance to client within 48 hours of request
•Responsible for calling the treating provider to discuss findings and recommendations, and to coordinate communication to patient and MD of any revised plan of treatments.
•May be responsible for calling client to discuss authorization and/or follow up on Plans of Treatment, continuation of care, or other clinical treatment recommendations
•Responds to the financial team’s requests within 48 hrs. in an effort to process claims received.
•Acts as a resource for other staff, answering questions and giving guidance when needed on clinical questions within their scope of practice.
•Works all special reports distributed by a supervisor/manager.
•Reviews and responds to any requests from clients, provider, claimant, or supervisor and performs necessary action steps within 48 hrs.
•Consistently demonstrates a positive attitude and an overall commitment to excellence and is a team player.
•Actively participates in continuous operational improvements. Specific activities include, but are not limited to, offering feedback to management related to process, working closely with provider development team to address provider issues, collaborating with financial team to improve efficiency and participates in training/mentorship initiatives
•Assists in obtaining necessary clinical documentation from provider as needed
•Is open to coaching and willing to find more efficient processes when applicable.
•Performs miscellaneous tasks and projects as assigned by management.
•Demonstrates knowledge of CPT and ICD9/10 codes
•Reviews and corrects in-accurate coding on referral
•Assists in provider appeals related to authorization or payment as needed and related to clinical determination
•Participates in provider scoring and complaint review as requested
•Utilizes and maintains general knowledge of insurance reimbursement and specific knowledge of One Call Care Management processes
•Participates in staff meetings, office presentations, training, orientation and conference calls, as directed
•May participate internal file QA to ensure appropriate care coordination internally

EDUCATIONAL REQUIREMENTS:

Licensed Clinician in field of work (Nursing, Dental Hygiene, physical Medicine) with requisite college degree for that license
AND Minimum of 5 years clinical experience in field of licensure

GENERAL KNOWLEDGE, SKILLS & ABILITIES:

•Ability to read, analyze and interpret medical reports, professional journals, newsletters, technical procedures, and/or government regulations. Ability to write business correspondence and completion of business forms.
•Ability to effectively present information and respond to questions from colleagues, Adjustors, Nurse Case Managers, Providers and Provider’s office staff.
•Ability to create and utilize Excel spreadsheets.
•Ability to define problems, collect data, establish facts and draw valid conclusions.
•Must have the ability to work with and have knowledge of the physician community, managed care, pre-certification, and utilization review.
•Must have knowledge of workers’ compensation.
•Must be able to collaborate with individuals at all levels of the organization.
•Knowledge of the Internet and how to research information is preferred
•Must be able to maintain a professional appearance and exhibit strong interpersonal, verbal and written communication skills for both internal and external customers.
•Must be able to organize work to ensure tasks are completed in a timely manner.
•Ability to respond to common inquires or complaints from customers
•To perform this job successfully, an individual should have knowledge of Microsoft Word; Microsoft Works; Microsoft Excel; Microsoft Internet Explorer; and Microsoft Outlook.
•Confidentiality

PHYSICAL/EMOTIONAL DEMANDS & WORK ENVIRONMENTS:

• For roles located in office or home settings; this job is primarily sedentary and may involve repetitive motions; the employee is regularly required to sit, use hands and fingers, speak, and hear
• For roles located in the field; this job is primarily active; the employee is regularly mobile and must be able to utilize transportation (such as driving), sit, use hands and fingers, speak, and hear
• The employee is occasionally required to stand, walk, and lift objects (up to 10 lbs. weight; up to 4 ft. height)
• Specific vision abilities required by this job include ability to see things from a close distance and ability to adjust focus
• The work environment utilizes florescent lighting; noise level is moderate
• The emotional demand of the job may cause undue stress from, but not limited to, moderate/heavy workload
• Reasonable accommodations will be individually assessed and possibly made to enable individuals with disabilities to perform the essential functions of the position
• Please be advised the job description is subject to change at any time

Clinical Reviewer III
RN - Five (5) years or more of work history in medical field including a minimum of three (3) years as a R.N.
Entry level reviewer role. Demonstrates strong clinical knowledge and experience to apply to clinical review/QA. Generally performs standard Clinical QA reviews. Works under supervision of Clinical Review Manager, but with latitude to make independent clinical recommendations. Consults with senior peers and team leads on non-complex issues to learn through experience.