Clinical Review Specialist

Job Description

Job Description

SUMMARY :

This position is responsible for maintaining proper clinical review and interpretation of medical records and claim documentation to assist with the appeals of denied insurance claims including drafting appeal letters based on clinical judgment and knowledge.

DUTIES AND RESPONSIBILITIES :

• Utilizes TimeMatters to obtain work assignments and communicates claim notes in a clear, concise manner.
• Examines and interprets medical records and claim documentation (such as EOBs and UB-04s) to appeal denied insurance claims for inpatient and outpatient services.
• Applies clinical judgment and knowledge for medical necessity, admission, and other clinical reviews.
• Drafts, reviews, and revises appeal letters, including from other staff.

Confirms that the correct letter format, guidelines, and argument were used.

Confirms the page number citations correspond with the medical record.

QUALIFICATIONS :

licensed as a Registered Nurse (including RN, APRN, CRNP), Nurse Practitioner (including CNP, LNP, NPC), Physician Assistant, Physician, or other qualified healthcare provider.

Knowledge in health, knowledge of current practices and documentation requirements regarding the care and treatment of the population served.

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COMPETENCIES : Select which competency categories are necessary for this position. We strongly recommend diversity and ethics to be included in each job description. Then select an additional 3-5 of the most critical competencies for the specific job title.

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COMPETENCIES :