Clinical Reviewer Job Description
Clinical reviewer
provides direct and constant guidance to Clinical Laboratory Technicians as required by applicable state and federal regulations.
Clinical Reviewer Duties & Responsibilities
To write an effective clinical reviewer job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical reviewer job description templates that you can modify and use.
Sample responsibilities for this position include:
Develops/maintains a working knowledge of all CareCentrix services and accesses CareCentrix contract information, including the terms of the contract as appropriate
Assists Team Leader in implementing/ maintaining standardized operational processes to ensure compliance to CareCentrix policies, legal requirements and regulatory mandates
Reviews and communicates all information with providers, utilizing computer database system for determining nursing facility placement appropriateness
Professionally develops and documents a clinical rationale supporting the review decision as the final step in the review process
Responsible for accurate and timely entry of data into the program’s database
This is a Part time position - Need detail oriented person, preferably with some clinical background and excellent computer skills, expert in Microsoft excel and access
Determines what medical information is needed to evaluate claim on ongoing basis
Responsible for clinical data listing review at protocol level to ensure data submitted by investigative sites is of high quality and completed within predefined study timelines
Demonstrates an understanding of the indication studied and the overall clinical data review goals in meeting the objectives of the protocol
Responsible for the identification and resolution of issues noted during clinical data listing review
Clinical Reviewer Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Clinical Reviewer
List any licenses or certifications required by the position: CPR, MBSAQIP, ACS, CPHQ, ACLS, MSCC, CPUM, CPUR, CCM, CDI
Education for Clinical Reviewer
Typically a job would require a certain level of education.
Employers hiring for the clinical reviewer job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Associates, Healthcare, Education, Health, Medical, Management, Graduate, Counseling, Health Care
Skills for Clinical Reviewer
Desired skills for clinical reviewer include:
Medical terminology
Applicable state and federal regulations
CareCentrix services and accesses CareCentrix contract information
Applicable state regulations
Chemotherapy authorization requirements for all payers
Diverse cultures and issues
With the ability to incorporate special needs into utilization review decisions
Profession and industry
State and federal regulatory guidelines for coverage and authorization
Accesses and uses other expert resources when appropriate
Desired experience for clinical reviewer includes:
Strong computer skills with access to high-speed internet service
Must be capable of day travel
Business attire required when visiting provider offices/facilities
Must be available and accessible during business hours
Minimum 5 years clinical experience and/or extensive ICD diagnosis coding knowledge required
Relevant chart review, audit or quality assurance experience (preferred)
Clinical Reviewer Examples
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Clinical Reviewer Job Description
Job Description Example
Our growing company is looking for a clinical reviewer. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for clinical reviewer
- Proactively collaborates with other study team members to address issues related to data quality at worldwide level
- Effectively uses available tools and systems to gather information needed to manage clinical data listing review, generate reports and to provide feedback to the appropriate BMS team members
- Main point of contact with the site facing role in the clinical data review process
- Contributes to non-project task forces, work streams and initiatives
- Implements clinical data review strategy to meet needs of protocol and ensure alignment with program level standards
- Demonstrates an understanding of the indication studied and the overall clinical data review goals in meeting the analysis and reporting objectives of the protocol
- Performs protocol level clinical data listing review, including more complicated protocol/TA listing review
- Provides clinical data review oversight of the protocol(s)
- Ensures there is consistency/accuracy in data review within the assigned protocols
- Supports and contributes to the development and embedding of new processes
Qualifications for clinical reviewer
- RN with current New York State License and a minimum of three years of progressive clinical experience or Certified Professional Coder (CPC) with a minimum of 6 months training environment and/or work coding experience required
- Familiarity and understanding of CMS HCC Risk Adjustment coding and data validation requirements (preferred)
- Computer proficiency including Excel, Word, Microsoft and other programs and applications
- Ability to medically review
- Ability to function under pressure and deadline oriented project demands manage multiple initiatives
- Must be a licensed Registered Nurse (RN)
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Clinical Reviewer Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of clinical reviewer. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical reviewer
- Reviews, processes and audits the medical necessity for each patient chemotherapy treatment and documentation of regimen relative to pathway adherence
- Communicates with nursing and medical staff to inform them of any restrictions or special requirements in accordance with particular insurance plans
- Updates coding/payer guidelines for clinical staff
- Obtains insurance authorization and pre-certification specifically for chemotherapy services
- Researches additional or alternative resources for non-covered chemotherapy services to prevent payment denials
- Adhere to chart migration priority as established by the clinic
- Monitor and update chart completion goals by entering completed work into spreadsheets or databases
- Participate in Quality Assurance review and resolution of discrepancies
- Conduct periodic comprehensive Quality Assurance checks at the request or direction of the Project Manager or clinic
- Enter diagnoses, medications, allergies, and other clinical data into Electronic Medical Record update following established data entry standards
Qualifications for clinical reviewer
- Preferred – RN with 10 years of recent acute care nursing experience, with expertise in Utilization Management / Case Management and/or coding
- Minimum 3 years of long term care experience required
- Must be able to travel based on client and business needs (50-75% within Ohio)
- Must live in or near St Louis, MO, Atlanta, GA, or San Francisco, CA
- Seven (7) plus years of experience in the role of a Study/Project Data Manager, Study Lead Monitor/Country Lead Monitor, Data Management Programmer or Statistical Analyst
- Good understanding of and experience in all aspects of data cleaning procedures
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Clinical Reviewer Job Description
Job Description Example
Our company is growing rapidly and is looking for a clinical reviewer. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for clinical reviewer
- Reviews and processes the medical necessity for each patient chemotherapy treatment or radiation and documentation of regimen based on specified guidelines
- Conduct completed evaluations prior to individuals nursing facility admissions
- Ensure accurate and timely trip report completion and trip report review
- Ensure timely filing of relevant sections of the TMF
- Comprehensive manual review of clinical data collected in trials
- Interface with Data Management team to assure query resolution
- Reviews, processes and audits the medical necessity for each patient's Radiation Therapy Services and documentation of regimen relative to pathway adherence
- Obtains insurance authorization and pre-certification specifically for Radiation Therapy Services
- Researches additional or alternative resources for non-covered Radiation Therapy Services to prevent payment denials
- Collaborate with providers and adhere to clinical standards of care to ensure appropriate outcomes
Qualifications for clinical reviewer
- Conducts self in an appropriate business manner adhering to a high ethical standard
- Must Live in San Francisco, CA OR Schaumburg, IL
- Kansas RN license
- Bachelors Degree in social, life, or health sciences, public health, health administration, or similar
- 2-3 years related work experience in health services research environment
- Training and/or knowledge in ethical conduct of research with human subjects
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Clinical Reviewer Job Description
Job Description Example
Our company is hiring for a clinical reviewer. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical reviewer
- Perform side-by-side comparison of both handwritten and digital material ensuring data accuracy
- Ensure changes are made accurately and documented appropriately
- Identify inconsistencies of information and where it is missing
- Perform standard calculations
- Flag any and all inconsistencies
- Conduct pre-certification and concurrent and retrospective clinical review of in-state and out-of-state inpatient cases at acute residential treatment programs and partial hospitalization through the application of evidence-based medical necessity criteria and BCBSMA policies and procedures
- Focus on efficient utilization management with emphasis on discharge planning
- Understand and appropriately manages member's benefits to maximize health care quality
- Collaborate with physician reviewers, case managers, project leaders and associates within BCBSMA to optimize member care and ensure a constructive provider experience
- Facilitate review process by communication with members/families, providers, medical staff and/or others to obtain and/or share information relating to benefits and the BCBSMA utilization management process
Qualifications for clinical reviewer
- Excellent problem-solving skills strong detail orientation and ability to adeptly manage multiple
- Must live in or near San Francisco, CA
- 4 to 6 years of experience in clinical data review or similar industry roles involved in data review/management
- Experience preferred in clinical data listing review and the use of data review tools
- Experience preferred in drug discovery / development process
- Demonstrated success in using oral and written communication skills to convey information and influence, inform, train and/or guide others
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Clinical Reviewer Job Description
Job Description Example
Our company is looking to fill the role of clinical reviewer. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical reviewer
- Identify and refer members who may benefit from high-risk case management and disease state management intervention
- Maintain professional licensure and seeks out continuous learning opportunities to enhance understanding of clinical management, trends in patient care, utilization management and other topics applicable to carrying out job responsibilities in an educated manner
- Utilize the computer systems to efficiently enter case information, check benefits and eligibility, look up policy and procedures, validate provider contractual status and other functions relating to the execution of key responsibilities
- Exhibit customer satisfaction orientation in every aspect of carrying out responsibilities
- Meet or exceed annual performance goal of 90% cumulatively for case audits and recorded call audits, were applicable
- Works collaboratively with Utilization Management Medical Director, Manger, and Supervisor(s)
- Assists Supervisor/Manager with coaching, training, call monitoring, reports and mentoring of new associates
- Assigns and prioritizes clinical cases for team member review based upon clinical urgency and turnaround times
- Acts as a clinical resource for unlicensed Utilization Review Care Coordinators, providing clinical expertise and helping to clarify referral source directives
- Makes on-going authorization decisions for health plans for which CareCentrix manages the reauthorization responsibilities
Qualifications for clinical reviewer
- Knowledge of techniques used to lead effective meetings and the use of presentations to communicate plans
- Skilled in the use of technology
- 5 to 7 years of experience in clinical data review and using eDC systems or similar roles in the industry related to data management/review
- Experience in drug discovery / development process
- Demonstrated success in using oral and written communication skills to convey information and influence, inform, provide training and/or guide others
- Experience working in a team environment within a matrix organization