Clinical Review Specialist

Description

The Clinical Review Specialist is responsible for proper clinical review and interpretation of medical records and claim documentation to assist with the appeals of denied insurance claims. Responsibilities include drafting appeal letters based on clinical judgment and knowledge. This is a remote position with the option to also work in the office should the candidate desire. On occasion, HLS may request with advance notice that the Clinical Review Specialist lead an in-person training or seminar with staff.

Hours

This is a part-time position with the potential to become full-time position. The position would be 15 hours per week to start with more hours potentially available depending on HLS’s workload and candidate’s availability.

Responsibilities

This is not an inclusive list. Other duties may be assigned. Familiarity with and ability to identify different types of hospital documentation including, but not limited to, medical records, UB-04s, EOBs, itemized bills, hospital account notes, appeal letters, and denial/approval letters.

• Utilize TimeMatters to obtain work assignments and communicate claim notes in a clear, concise manner.
• Examine and interpret medical records and claim documentation (such as EOBs and UB-04s) to appeal denied insurance claims for inpatient and outpatient services.
• Apply clinical judgment and knowledge for medical necessity, admission, and other clinical reviews.
• Draft, review, and revise appeal letters, including from other staff.
  • Confirm that the correct letter format, guidelines, and argument were used.
  • Confirm letters are logical and easy to comprehend.
• Ensure all necessary attachments are noted and included with appeal.
  • Confirm the page number citations correspond with the medical record.
• Turn around high dollar and/or short deadline cases in a timely manner.
• Send all appeals, follow-ups, and other forms of documentation within timely filing periods.
• Abide by all HIPAA and other compliance rules and regulations.
• Assist with development of clinical training materials for other staff
• Assist with clinical training of other staff

Required Qualifications

Bachelor's degree from four-year college or university. The Clinical Review Specialist should be licensed as a Registered Nurse (including RN, APRN, CRNP), Nurse Practitioner (including CNP, LNP, NPC), Physician Assistant, Physician, or other qualified healthcare provider. Current active licensure is not required.

Compensation

• $45+ per hour depending on candidate’s qualifications
• Eligibility for monthly bonuses after 90 days of employment
• If converted to full-time, other benefits including 401k, health insurance, disability insurance, and commuter benefits are available.