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Required Function 1:
Responsible for performing clinical reviews of medical information and quality assurance as defined by review methodologies specific to the contract for which services are being provided.
Required Function 2:
· Performs precertification and retrospective medical record reviews, data collection and database entry.· Assigns case reviews by identifying the issues for review and the specialty of the physician reviewer necessary to complete the peer matched review.· Provides supporting reference documentation to the reviewer.· Applies state laws during the Quality Assurance process.· Interacts with physician reviewers.· Assists in the transcription of physician reviews by editing and formatting, as needed.· Assures that all work is completed within contractual deadlines and that all components of the completed review are present.
Required Function 3:
· Delivers final product to the client per client specific contractual guidelines.· Communicates with appropriate parties regarding review (enrollee, authorized representative, health plan representative, facility and state department of insurance).· Receives requests for precertification of procedures via telephone, fax, or Web.· Utilizes clinical expertise to approve services or refer requests to a physician for review.· Oversees referrals to and from physician review.· Formats and edits approval and denial letters.· Performs retrospective chart review per contract specifications.· Prepares letters to summarize retrospective review activity.· Evaluates, identifies, and reports on, quality of care issues.· Communicates with health care professionals as a liaison regarding contract specifications and escalates issues as appropriate.· Participates on quality improvement teams.· Facilitates quality improvement plan development and implementation as requested, both internally and with external customers.· Participates in the project data analysis, reporting, and feedback processes.
Required Function 4:
Minimum Education: Associate's degree or diploma (Nursing program) required; Bachelor's degree preferredCertifications: (Required/Desired)Unrestricted RN license
Required Function 5:
3+ years clinical experience in behavioral services, preferably inpatient hospitalization1+ year utilization review experience, preferably in all behavioral health levels of care
Additional Job Requirement 1:
· Ability to communicate both verbally and in writing fluently in English.· Ability to work proficiently with Microsoft Word, Excel, and Power Point.· Ability to analyze and evaluate medical information.· Ability to provide good customer service skills.· Ability to medically review; chart audits, and quality improvement processes.· Ability to travel 10%.· Ability to sit and work at a computer for an extended period of time.· Average manual dexterity in use of a PC, phone, sorting, filing and other office machines.· Ability to perform well in team environment, with staff at all levels, to achieve business goals.· Ability to function under pressure and with deadline oriented project demands as well as manage multiple initiatives.· Ability to apply existing knowledge of health care marketplace including commercial and government insurance health plan organizations and HIPAA guidelines with their associated security requirements.· Ability to work independently to meet predefined production and quality standards· Working knowledge in and successful application of basic level of health care data analysis and clinical review.· Writes articles for newsletters as requested and participates in provider training as needed.· Ability to travel 10%
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