Clinical Review Specialist

DHRM • Staunton, VA

5d

About The Position

The Clinical Review Specialist evaluates the delivery of care through the Utilization Review (UR) process and performs data collection, analysis, and reporting. The role communicates with Medicaid and private insurance third-party payers and regulatory agencies, and has employee health responsibilities. The position requires psychiatric and clinical nursing expertise, an active RN license, and an associate degree in nursing (ASN).

Requirements

• Psychiatric and clinical nursing expertise.
• Demonstrated knowledge of inpatient psychiatric treatment and documentation requirements under state and federal Medicaid regulations.
• Knowledge of HIPAA and compliance regulations.
• Ability to analyze complex clinical documentation, identify discrepancies, recommend improvements, and facilitate ongoing quality enhancement.
• Effective oral and written communication with clinicians, administrators, patients, patients’ families, and external agencies.
• Basic computer proficiency, including typing and knowledge of Microsoft Word and Microsoft Excel.
• Associate degree in nursing (ASN).
• Active RN license.
• Clinical delivery experience in an inpatient psychiatric setting.

Nice To Haves

• Bachelor of Science in Nursing (BSN) preferred.
• Prior experience in data management and analysis, utilization review, Medicaid, and third-party commercial insurance preferred.
• Experience with medical reviewers preferred.
• Experience with Joint Commission standards preferred.

Responsibilities

• Evaluate delivery of care through the Utilization Review (UR) process.
• Collect, analyze, and report data.
• Communicate with Medicaid and private insurance third-party payers and regulatory agencies.
• Perform employee health responsibilities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree