Senior Clinical Reviewer

Christian Care Ministry•Orlando, FL

3d•$32 - $44•Hybrid

About The Position

The Senior Clinical Reviewer works to summarize and correlate concise, accurate information on medical reviews to determine eligibility of medical bills per the program guidelines. In this role, 70% of the time is spent performing pre-service and post-service medical reviews and/or reviews for high dollar, complex medical cases and collaborating with other departments to optimize cost savings. This position leverages AI-enabled clinical review tools and electronically ingested data (278 transactions) to enhance the accuracy, efficiency, and consistency of medical reviews. The Senior Clinical Reviewer will be expected to make decisions regarding timing and omission of medical reviews in deference to other department processes based on the dollar amount of the bill and the Ministry’s cost strategy.

Requirements

Understanding of medical bill processing and provider bill negotiation
Knowledge and practical application of AI-assisted medical review tools and clinical decision support technologies
Ability to understand Availity 278 transactions and electronic pre-service eligibility workflows
Ability to interpret structured electronic data and integrate it with clinical documentation during the medical review process
Ability to multitask in multiple operating systems
Ability to work for extended periods of time on the computer
Proficiency in interpreting medical records and writing detailed reports and conclusions
Strategic understanding of negotiations, third party processes, bill validation, and care management to determine when to utilize/defer to these processes for active review cases
Ability to be objective and impartial and conclude a case
Ability to communicate effectively with both internal and external customers
Interpersonal skills and ability to work as a member of a team
Ability to adapt to changing processes
Working knowledge and application of program guidelines
Understanding of systems and workflows as they relate to the type of review or assignment
Ability to utilize the internet including e-mail and search engines
Word processing skills of at least 25 wpm
Basic knowledge in Microsoft Office (Excel, Word, Outlook, Teams) and ability to use a database system
Knowledge of document imaging system
Current Unrestricted LPN/LVN license with 5+ years’ experience in a healthcare payer industry or RN license with sound knowledge of anatomy and physiology and disease processes
1-3 years’ experience in medical reviews required
2-3 years of clinical experience strongly preferred
Experience with Utilization Review or Case Management preferred

Nice To Haves

Action Oriented – taking on new opportunities and tough challenges with a sense of urgency, high energy, and enthusiasm
Plans and aligns – planning and prioritizing work to meet commitments aligned with organizational goals
Member First – exhibits full commitment to serving members and/or clients by prioritizing their needs first in alignment with our program’s purpose. This commitment is demonstrated through understanding of the program(s), provided through quality and timely service while exercising empathy in every interaction. Every CCM employee shares responsibility to steward resources faithfully, removing barriers to understanding, and creating accessible, connected, and Christ-centered experiences.
Humble – demonstrates Christ-Centered humility by honoring others, accepting feedback, and prioritizing collective success over individual recognition
Hungry – exhibits initiative, perseverance, and commitment to serving God through excellence. Demonstrates passion for personal and organizational growth while diligently advancing the mission of Christian Care Ministry
Smart – shows relational and emotional intelligence, communicates effectively, collaborates harmoniously, and reads social cues with grace and discernment

Responsibilities

Organize and review medical records, lab results, radiology, and pathology reports for conditions ineligible for sharing (CIF’s)
Determine eligibility of members’ medical bills and/or upcoming procedures/treatments according to the program guidelines
Perform pre-service and post-service medical reviews utilizing AI-enabled clinical review tools to make evidence-based, consistent, and efficient determinations of sharing eligibility
Review and interpret pre-service eligibility data (via 278 EDI transactions) to support streamlined medical review workflows
Integrate structured electronic data with clinical documentation to support accurate and timely eligibility determinations
Collaborate with other departments to maximize cost savings for individual cases and optimal outcomes for the members
Appropriately apply the program guidelines to the individual cases reviewed
Work autonomously to prioritize and manage workload
Document effectively in appropriate systems, including outputs supported by AI tools and electronic data ingestion processes
Comply with all organizational HIPAA requirements and ensure proper handling of electronic transaction data
Support process improvements related to automation, using AI tools and electronic data ingestion workflows
Contribute to the exercise and expression of the Ministry’s Christian beliefs
All other duties as assigned

Benefits

100% paid Medical for employees/99% for family
Generous employer Health Savings Account (HSA) contributions
Employer-paid Life Insurance (3x salary) and Long-term Disability Insurance
6 weeks of paid parental leave (for both mom and dad)
Dental - two plans to choose from
Vision
Short-term Disability
Accident, Critical Illness, Hospital Indemnity
401(k) – up to 4% match on ROTH or Traditional contributions
Generous paid-time off and 11 paid holidays
Wellness plan including Financial, Occupational, Mental/Spiritual, and Physical health incentives up to $50/mo
Employee Assistance Program including no cost, in-person mental health visits and employee discounts
Monetary Anniversary Awards Program
Monetary Birthday Awards
Tuition Reimbursement Program