Clinical Review Specialist

CorroHealth

8d • Remote

About The Position

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success. JOB SUMMARY: ESSENTIAL DUTIES AND RESPONSIBILITIES: Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member. Location: Remote within the United States ONLY Schedule: Monday - Friday, 8:00 AM - 5:00 PM As a Clinical Review Specialist, you will have the unique opportunity to evaluate hospitalizations across the country while utilizing your medical knowledge and gaining experience as an expert advisor. You will perform retrospective clinical case reviews and draft appeals that focus on establishing the Medical Necessity of the services performed, both Inpatient and Outpatient.

Requirements

• RN License with strong clinical knowledge - Active unrestricted clinical license in at least one state within the United States.
• Minimum of 2-3 years of writing appeals letters and clinical auditing.
• Minimum of 2-3 years Utilization Review / Case Management experience within the last 5 years.
• Must be familiar with the payer guidelines and EMR systems like Epic, Cerner or Meditech.
• Must have excellent attention to detail, written communication skills and be computer proficient.

Nice To Haves

• Managed care payor experience a plus in either Utilization Review, Case Management or Appeals.

Responsibilities

• Performs retrospective medical necessity reviews to determine appeal eligibility of clinical disputes/denials.
• Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate medical necessity criteria and other pertinent clinical facts.
• Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appeal process.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees