Clinical Reviewer Resume Samples
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Clinical Reviewer Resume Samples
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JH
J Hyatt
Jermey
Hyatt
94610 Enoch Station
Detroit
MI
+1 (555) 651 9532
94610 Enoch Station
Detroit
MI
Phone
p
+1 (555) 651 9532
Experience
Experience
Phoenix, AZ
Clinical Reviewer
Phoenix, AZ
Grant-Yost
Phoenix, AZ
Clinical Reviewer
- Performs TAR reviews and completion of TAR requests according to Medi Cal format and deadlines
- Receives and responds to requests from unlicensed staff regarding scripted clinical questions and issues
- Performs on line documentation of clinical justification for hospital stays and pre screening of files to determine if Appeal is warranted
- Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking
- Maintain individual records documenting all applicant/participant encounters and contacts; write clinical summaries
- Performs clinical intake and reviews cases according to the policies and procedures of TOG
- Collects and enters confidential information ensuring the highest level of confidentiality in all areas
Los Angeles, CA
Senior Appeals Clinical Reviewer
Los Angeles, CA
Marvin-Feil
Los Angeles, CA
Senior Appeals Clinical Reviewer
- Schedules/triages work, evaluating staff caseloads, and redistributing cases as necessary
- Review daily/weekly reports to monitor appeals inventory and ensure timeframes are met
- Evaluate individual staff performance on an ongoing basis, and develop individual performance improvement and/or professional improvement plans with staff
- Participate in the recruitment of qualified candidates for all open positions and arrange and monitor the training process for new staff members. Monitor performance and address any problems during the probationary period
- Oversee employee development and training on all products
- Participate in planning and leading team meetings to foster communication and collaboration within the team
- Participate in the recruitment of qualified candidates for all open positions and arrange and monitor the training process for new staff members. Monitor their performance and address any problems during the probationary period
present
Houston, TX
Senior Recovery Resolution Analyst M&R Appeal Clinical Reviewer
Houston, TX
Rau-Cremin
present
Houston, TX
Senior Recovery Resolution Analyst M&R Appeal Clinical Reviewer
present
- Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits information
- Works with less structured, more complex issues
- Generally, work is self - directed and not prescribed
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
- Process recovery on claims
- Use pertinent data and facts to identify and solve a range of problems within area of expertise
- Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
Education
Education
Associate’s Degree in Nursing
Associate’s Degree in Nursing
Strayer University
Associate’s Degree in Nursing
Skills
Skills
- Ability to work in a highly computerized environment
- Convey a strong professional image, exhibit interest and positive attitude toward all assigned work
- Negotiation (ability to resolve disputes and craft outcomes that address competing interests while achieving business objectives
- Focus (ability to identify and manage to key, high-leverage information, tasks, and events)
- Health care professional with active Massa1husetts license
- Call management (ability to conduct telephone conversations that ensure value in every contact, achieve the desired objectives for placing the call, and are efficient and professional)
- Comfort and proficiency with the use of computers and technology (ability to navigate computer applications quickly and effectively, key in data proficiently in real time during phone calls, work effectively with the phone system, and quickly learn, and effectively work in, a variety of media)
- Management of the end to end episode of care (ability to effectively understand the described clinical condition, evaluate effectiveness of a proposed plan of care, identify the most appropriate site of service, recognize gaps in care and opportunities to coordinate services, ensure appropriate discharge planning, aftercare, and continuity, and apply differential levels of activity and involvement in cases based upon potential impact)
- Productivity (ability to prioritize and manage assigned workload to accomplish full slate of targeted activities)
- Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices
15 Clinical Reviewer resume templates
Read our complete resume writing guides
1
Bariatric Clinical Reviewer Resume Examples & Samples
- Responsible for assuring the highest possible data quality through accurate, complete, and timely data entry and abstraction for the ACS MBSAQIP database for 100 percent of bariatric procedures for both Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital
- Serve as an active participant in the Brigham & Women’s Faulkner Hospital continuous quality improvement program through various efforts including distribution and presentation of data and appropriate follow-up. This includes, but is not limited to participation in the BWFH Bariatric Improvement Team and quarterly quality data reporting to the BWFH Department of Quality Improvement. The position is accountable to the BWFH Director of Quality for these responsibilities
- Utilize database reports, Epic and the ACS MBSAQIP Bariatric Database to identify the complete capture of information for all bariatric patients. Utilize multiple systems to retrieve registration, demographic, medical history and various perioperative data elements for bariatric patients
- Prepare ACS MBSAQIP outcomes data reports for presentation to bariatric team and hospital administration. This position serves as an active member of the Partners Bariatric Surgery Collaborative Committee, the CMBS Bariatric Program Meetings and M&M’s, as well as the BWFH Bariatric Improvement Committee to encourage a culture of best practices for the bariatric population. The MBSCR participates in data compilation for audits and accreditation site visits and is responsible for assisting with the development and management of the accreditation process through continuous compliance with MBSAQIP requirements
- Act as project manager in regards to developing the data collection process and accuracy. This includes, but is not limited to
- Performs other duties as assigned by the Bariatric Program Manager
- Bachelor’s degree required in anatomy and physiology, life sciences, nutrition, nursing, or similar health science field
- Knowledge of human anatomy, physiology, medical terminology, organization of medical records and clinical coding systems (ICD-10 and CPT)
- Computer and Internet experience required. A familiarity and comfort with Microsoft Office products is essential for success in this position (Word and Excel experience are required; PowerPoint and Access experience are preferred)
- Basic statistical knowledge is preferred
- Excellent typing and editing skills; advanced computer skills
- Advanced database management and project management skills, specifically related to quality improvement, are required
- Customer service skills required
- Candidate must be able to complete all ACS MBSAQIP training modules and pass the certification examination with a minimum score of 90 percent at least one month after start date
- Candidate must maintain ACS MBSAQIP certification by completing annual training provided by ACS
- Ideal candidate will be well organized, detail-oriented, and possess the ability to work independently
- Candidate must have the ability to interact with all members of the bariatric surgical team and administrative staff in a professional and courteous manner
- Candidate must have the ability to use critical thinking, problem solving and good judgment
- Must be able to balance multiple priorities and work well under pressure
- Must be a team player who enjoys dealing with people both in the office environment and via the telephone
- Good patient interaction skills and a commitment to customer service are essential
- Advanced computer skills
2
Clinical Reviewer Resume Examples & Samples
- Documents clinical justification for Appeal requests
- Performs clinical intake and reviews cases according to the policies and procedures of TOG
- Preferred RN from an accredited school of nursing
- Preferred Current, active California RN license
- 2-3 years experience in acute care environment
- 3 years previous utilization management experience in a managed care and/or hospital setting
- An associate or bachelor's degree in nursing or a hospital-sponsored diploma
- Program
- Knowledge and proficiency of established clinical standards and guidelines with Medi-Cal
- Good organizational skills preferred
- Experience in both nurse review and assisting with the utilization review appeals process
3
Clinical Reviewer, LOC / Level Resume Examples & Samples
- Complete pre-admission and concurrent reviews for admissions and continued placement in Medicaid certified nursing facilities, utilizing federal and State’s criteria
- Reviews and communicates all information with providers, utilizing computer database system for determining nursing facility placement appropriateness. Utilizes both referral screens and medical records review to make determinations
- Professionally develops and documents a clinical rationale supporting the review decision as the final step in the review process. Must work within a tight turnaround time assuring contract compliance
- Perform all job duties in compliance with Person First standards, HIPAA guidelines, and company confidentiality policies and procedures
- Performs other duties as assigned by management
- High School Diploma or equivalent GED is required. Graduation from an accredited school of nursing, with current Tennessee LPN license, in good standing
- Minimum of two (2) years of medical experience with a strong understanding of rehabilitation potential, based on diagnosis, age, disease process and chronicity
- 2 years of experience working with individuals with a mental health diagnosis and/or intellectual disability, with a primary focus on behavioral health
- Excellent knowledge of diverse cultures and issues, with the ability to incorporate special needs into utilization review decisions
- Knowledge and understanding of behavioral health diagnoses, psychotropic medications, medical diagnoses and prescribed medications
- Excellent ability to multitask while effectively performing job duties, which include prioritizing tasks
- Respond promptly within 2 hours of receipt of emails and voicemails
- Ability to work independently, as well as within a team while exhibiting excellent interpersonal skills
4
Clinical Reviewer Resume Examples & Samples
- Candidate will possess excellent communication (verbal/written), organizational and interpersonal skills
- Using clinical expertise, reviews utilization information concerning patient care and matches those needs to available care options, within the CareCentrix guidelines and specific plan payer criteria
- Verifies completed case verifications funneled through Triage, verifying information, applying business rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge
- Receives/responds to incoming calls from referral sources/potential clients, exchanges information to identify the clients’ needs and determines CareCentrix' ability to meet them
- Receives and responds to requests from unlicensed staff regarding scripted clinical questions and issues
- Holds all referrals until all information is verified as complete and the next steps are determined
- Records the outcome of all inquiries and referral calls received, and makes follow - up calls when an inquiry or referral cannot be serviced. Tracks/reports on inquiries/referrals and identifies alternative resources when CareCentrix solutions are not available
- Performs an initial evaluation of the referrals appropriateness for CareCentrix services, researches/identifies all potential payer sources and determines the primary payer. Documents demographic/clinical/payer information and determines coverage availability for requested services and passes information on in a timely manner
- Recommends to Team Leader - Intake the acceptance of referrals that do not meet CareCentrix guidelines as appropriate. Coordinates internal activities to ensure a smooth transition from CareCentrix to the provider
- Develops/maintains a working knowledge of all CareCentrix services and accesses CareCentrix contract information, including the terms of the contract as appropriate. Interacts with referral sources to facilitate communications, answer questions and resolve problems
- Participates in ongoing utilization management activities and quality assessment/improvement activities, ensures the collection of data for improvement analysis and prepares reports as requested
- Assists Team Leader in implementing/ maintaining standardized operational processes to ensure compliance to CareCentrix policies, legal requirements and regulatory mandates. Follows Utilization Management and URAC standards
- Attends/participates in staff development programs and obtains continuing education as required by company policy. Provides back up support to the Team Leader to ensure that intake operations are maintained
- Participates in special projects and performs other duties as assigned
5
Bariatric Surgery Clinical Reviewer Resume Examples & Samples
- Bachelor degree from accredited college or university
- Two (2) years of related work experience OR
- Four (4) years of work experience In Lieu of Education
6
Per Diem Clinical Reviewer Resume Examples & Samples
- Accurately and efficiently conducts medical record review, including but not limited to, HEDIS/QARR, CMS (Centers for Medicare and Medicaid Services), DOH requests, Pre-natal/Postpartum Reporting, and ad hoc requests from Medical Directors or other departments in Health plan
- Successfully completes required training, testing and quality assessments
- Travels from home to provider offices or facilities to complete reviews, if required
- Abstracts data from medical records, uses portable scanner to retrieve relevant components from medical record and upload scanned medical records daily, as required
- Maintains daily communication with management
- Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct
- Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures
- Regular and reliable attendance is expected and required
- Performs other functions as assigned by management
7
Clinical Reviewer Resume Examples & Samples
- Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis
- Convey a strong professional image, exhibit interest and positive attitude toward all assigned work
- Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices
8
Clinical Reviewer Resume Examples & Samples
- Registered Nurse with an Ohio license
- Has at least one year of experience as a home care professional nurse
- Prefer a BS in Nursing from an accredited program by the National League of Nursing
- Has worked as a professional nurse at least one year within the last three years or completion of a refresher course in the last year
- Access to utilization of public or private transportation system
- Ability to lift, push, pull light to moderate load
- Read, write, and communicate in English
9
Clinical Quality Liaison Clinical Reviewer Resume Examples & Samples
- Develop collaborative relationships with assigned CSBs
- Conduct regular meetings focused on continuous quality improvement
- Partner on metrics and dashboard components
- Provide technical support for outcomes measurement
- Conduct review audits to evaluate compliance with State requirements
- Serve as the primary point of contact with CSBs on the Partners in Care program
- Coordinate exchange of best practices among CSBs
- Work with Magellan clinical and network staff to coordinate clinical and quality activities with the CSBs
10
Physician Clinical Reviewer Resume Examples & Samples
- Reviews all cases in which clinical determinations cannot be made by the Initial Clinical Reviewer
- Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request by phone or fax
- Provides clinical rationale for standard and expedited appeals
- Provides assistance and act as a resource to Initial Clinical Reviewers as needed to discuss cases and problems
- Participates in daily review of aggregate denials/appeals with appropriate staff/leaders
- Utilizes medical review guidelines and parameters to assure consistency in the MD review process so as to reflect appropriate utilization and compliance with SBU's policies/procedures, as well as URAC and NCQA guidelines
- Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner
- Participates in on-going training per inter-rater reliability process
- Assists the Clinical Advisor and/or Medical Director in research activities related to Utilization Management Information Systems (database development/outcomes reporting)
11
Initial Clinical Reviewer Resume Examples & Samples
- Bachelor's or higher degree in a health-related field
- Licensure as a Registered Nurse required
- Three (3) years of clinical experience with a focus on orthopedic, neurological, rehabilitation, medical/surgical, or occupational health
- Workers' Compensation Utilization Management or case management experience a plus
- Professional certification as CCM, CDMS, SRS, CVE, and/or CRRN a plus
- Superior analytical and critical thinking skills
- Ability to use computer technology to efficiently perform job functions
- Excellent time management abilities
12
Nsqip Surgical Clinical Reviewer Resume Examples & Samples
- 5 years Perioperative experience including one year experience in hospital surgery department, surgery clinic, clinical research, or medical records
- Experience with clinical chart reviews
- Skills to articulate questions to receive an appropriate level of support from superiors and peers
- Quality improvement or patient safety knowledge and experience
13
Senior Appeals Clinical Reviewer Resume Examples & Samples
- Manage the day-to-day operations of the Medicare appeals team. Ensure the appropriate staff responds to all member/provider inquiries accurately and within the stipulated time frames, thereby ensuring member/provider satisfaction, and compliance with regulatory and accreditation requirements
- Carry partial clinical appeals caseload, utilizing the appropriate clinical criteria, CMS and state guidelines, and medical and administrative policies to evaluate medical necessity
- Schedules/triages work, evaluating staff caseloads, and redistributing cases as necessary
- Review daily/weekly reports to monitor appeals inventory and ensure timeframes are met
- Evaluate individual staff performance on an ongoing basis, and develop individual performance improvement and/or professional improvement plans with staff
- Participate in the recruitment of qualified candidates for all open positions and arrange and monitor the training process for new staff members. Monitor performance and address any problems during the probationary period
- Oversee employee development and training on all products
- Participate in planning and leading team meetings to foster communication and collaboration within the team
- Create and implement policies and procedures to ensure department goals are met using the most efficient and cost effective measures
- Participate in creating and implementing continuous process and quality improvement initiatives. Conduct root cause analyses and implement process improvements based on findings. Track and trend outcomes, analyze data, report on these to the Director, and recommend modifications to medical necessity criteria, etc., based on trends found for appeals upheld or reversed. When modifications are made, track to measure impact on appeals decisions
- Prepare for and acts as business area liaison for internal and external audits
- Act as a liaison between the Appeals department and other departments. This includes dissemination of accurate, up-to-date information to staff, representing the department in committees and work groups, and facilitating resolution of interdepartmental issues
- Interface with various external customers, including but not limited to, delegates, and accreditation, federal, and state agencies. This involves explaining ConnectiCare’s policies and processes as they relate to the external entity, negotiating the resolution of issues, developing workflows, and implementing quality improvements
- Participate in the recruitment of qualified candidates for all open positions and arrange and monitor the training process for new staff members. Monitor their performance and address any problems during the probationary period
- Perform other related projects and duties as assigned
- CT R.N. License. Bachelor’s Degree in nursing or an equivalent combination of education and experience
- At least 5 years of clinical experience
- At least 3 years in a managed care health care environment, including 2 years’ experience in Medicare managed care. Familiarity with applicable state regulations and NCQA standards required
- Supervisory skills sufficient to direct, motivate, and discipline staff are essential
- Must possess initiative, balanced judgment, objectivity and the ability to plan and prioritize one's own work to assure maximum efficiency
- Analytical and technical ability is required to review and analyze appeals outcomes, procedures and workflow and to make recommendations for streamlining the grievance and appeals process within the functional units of the department
- Demonstrated ability to synthesize and process complex information and deliver the information, both verbally and written, in a clear, concise, and articulate manner
- Excellent organization and interpersonal skills are required to interact effectively with all levels of staff
- Must have the ability to prioritize a heavy workload in a dynamic, fast paced environment
- The incumbent must exercise sound decision making in line with the responsibilities of the position and seek assistance when necessary. This includes the ability to set priorities and complete assignments in a timely fashion
14
Clinical Reviewer Resume Examples & Samples
- Administration of member benefits for coverage of health services in compliance with applicable regulatory and accreditation requirements
- Dealing w/ambiguity (Ability to adapt, demonstration of insight, self-direction and self-discipline)
- Flexibility/ Adaptability (Coping) (Adaptability, a calm demeanor and an understanding of the situation)
- Execution and results (ability to set goals, follow processes, meet deadlines, and deliver expected outcomes with appropriate sense of urgency)
- Communication (ability to articulate complex concepts, verbally and in writing, in decisive and focused manner)
- Builds effective relationships (ability to establish and maintain productive partnerships, internally and externally, in person and virtually, in order to facilitate professional and business goals)
- Managed Care and health care landscape insight (demonstrates nuanced understanding of products, benefits, healthcare delivery system, accreditation and regulatory requirements, and community resources)
- Business Insight (Demonstrates an understanding of the utilization management process and its business implications, and awareness of current / future policies, practices, trends, and information affecting the business and organization)
- Focus (ability to identify and manage to key, high-leverage information, tasks, and events)
- Consistency (ability to follow identified workflows, plan requirements, clinical guidelines, and make sound, objective decisions)
- Negotiation (ability to resolve disputes and craft outcomes that address competing interests while achieving business objectives
- Call management (ability to conduct telephone conversations that ensure value in every contact, achieve the desired objectives for placing the call, and are efficient and professional)
- Clinical review (ability to evaluate the path of a given condition, the level of clinical risk, the implications for the care needed / site of service required, and the likely cost of services)
- Productivity (ability to prioritize and manage assigned workload to accomplish full slate of targeted activities)
- Management of the end to end episode of care (ability to effectively understand the described clinical condition, evaluate effectiveness of a proposed plan of care, identify the most appropriate site of service, recognize gaps in care and opportunities to coordinate services, ensure appropriate discharge planning, aftercare, and continuity, and apply differential levels of activity and involvement in cases based upon potential impact)
- Comfort and proficiency with the use of computers and technology (ability to navigate computer applications quickly and effectively, key in data proficiently in real time during phone calls, work effectively with the phone system, and quickly learn, and effectively work in, a variety of media)
- Health care professional with active Massa1husetts license
- 3 years direct clinical experience preferred
- Managed care experience preferred
- For Behavioral Health and other specialty programs or account teams, additional requirements will apply which may include master’s degree and independent licensure to practice
- Ability to work in a highly computerized environment
15
Clinical Reviewer Resume Examples & Samples
- Facilitate and obtain appropriate provider documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care for the patient
- Collaborate under the supervision of the Risk Adjustment Director and Medical Director to communicate and coordinate review findings in a consistent manner
- Assess and review data to determine areas of improvement for follow up provider training and communication
- Prepare work papers/spreadsheets to collect and support chart review findings
16
Clinical Reviewer Resume Examples & Samples
- Upon suspicion of MI conduct in-person evaluations to confirm the presence of MI, whether a nursing facility is the most appropriate setting and whether the individual has a need for specialized services
- Conduct completed evaluations prior to individuals nursing facility admissions; completed evaluations on individuals residing in a nursing facility when there are significant changes that signify the need for an updated evaluation
- Complete evaluations on an individualized basis, but in accordance with the most current federal rules, regulations, and evaluative criteria
- Communicate all evaluation findings to applicants, residents and/or guardians in an understandable manner and language
- Communicate determinations that identity a need for specialized services to the facility, agency, or referrals source, within appropriate timelines and data transmission policies
- Contact providers, state agency offices, and applicants/participants to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination
- Review and document all relevant information into data system applications in accordance with program guidelines and regulations
- Maintain individual records documenting all applicant/participant encounters and contacts; write clinical summaries
- Prepare and respond to requests for statistics and resource/service data
- Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals, long term care facilities and other programs/organizations involved in the provision of services
- Participate in public relations efforts, attending conferences and meetings as needed
- Maintain positive working relationships with applicant/participants, and relevant informal supports, provider organizations, program consultants and state agencies
- Maintain the confidentiality of all business documents and correspondence per UMMS/CWM procedures and HIPAA regulations
- Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations
- Comply with established departmental policies, procedures and objectives
- Comply with all health, safety and program regulations and requirements
- Master’s degree in social work; mental health counseling; related health and human services field; or equivalent OR a registered nurse (RN)
- 5 years of work experience providing direct service or case management to adults with psychiatric disabilities inclusive of 1 year of experience in a medical or clinical setting with knowledge of medical terminology. (If a Registered Nurse, must have a minimum 9 years of collective relevant education and work experience as outlined above)
- Demonstrated knowledge and experience with relevant social service/rehabilitation systems
- Ability to travel statewide
- Proficient in the use of Microsoft Applications, including Word, Outlook and database
- Massachusetts licensed Psychologist, Licensed Social Worker, Certified Rehabilitation Counselor or other licensed professional
- Experience with disabled or long term care populations
- Experience in community mental health services and one of the following areas: Long-Term Care, Home Care, Rehab, and/or Disabilities
- Ability to understand and utilize resources for problem solving, in order to deal with problems involving multiple variables, effectively prioritizing and executing tasks in a high-pressure environment
17
Quality Clinical Reviewer Resume Examples & Samples
- Audits and reviews case manager and provider clinical documentation and telephone interactions against regulations, accreditation standards and contract requirements. Reviews provider treatment records against clinical and procedural established standards
- Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for care managers
- Conducts reviews of Quality of Care and Critical/Adverse Incidents
- Evaluates level of patient safety risk and need for follow-up actions per policies
- Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services. Prepares monthly performance reports with assistance from Reporting and Analytics unit. Presents findings at provider and customer meetings as needed
- Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and care managers
- Responsible for auditing as well as validating internal audit results and/or corrective action plans
18
Senior Recovery Resolution Analyst M&R Appeal Clinical Reviewer Resume Examples & Samples
- Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
- Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
- Investigate and pursue recoveries and payables on subrogation claims and file management
- Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits information
- Process recovery on claims
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
- Generally, work is self - directed and not prescribed
- Works with less structured, more complex issues
- Ability to work on the computer while on the phone
19
DRG Clinical Reviewer Resume Examples & Samples
- Knowledge of age specific needs and the elements of disease processes and related procedures
- Strong broad-based clinical knowledge and understanding of pathology/physiology
- Excellent written and verbal communication skills and critical thinking skills
- Ability to work independently in a time-oriented environment
- Assertive personality traits to facilitate ongoing physician communication
- Working knowledge of Medicare reimbursement system and coding structures preferred
- Working knowledge of core measures preferred
20
Bariatric Clinical Reviewer Resume Examples & Samples
- Experience: Minimum of one year in a hospital surgery department, surgery clinic or post surgical unit. Must have clinical knowledge and understanding of patient care
- Certifications: Must complete three training modules with a minimum score of 90% within 30 days of hire
- Other: Clinical chart review and abstraction required. Must be able to gather information in a complex hospital environment. Must have the ability to identify opportunities to report bariatric data to relevant groups or meetings. Comfortable speaking in front of an audience. Familiarity with Microsoft word & excel with ability to learn new database applications
21
QM Clinical Reviewer Resume Examples & Samples
- Serves as a resource and subject matter expert on Quality Management processes
- Engages and educates providers about the value of the program and content of reporting
- Performs comprehensive review of medical information, identifies and collects determinants of member health, identifies and documents gaps in care, assists health care analytics in providing critical analysis of the collected information and provides appropriate reporting of analyzed data to providers
- Reviews medical records for under reported, under documented and undocumented burdens of illness and gaps in care
- Ensures proper assignment of ICD-10 codes to identified conditions. Engages and educates members of the Quality Management Medical Reviewer team, other areas of the company and external stakeholders
- 2 years of experience as a medical chart reviewer preferred
- Foreign medical graduate or foreign physician preferred
