A Clinical Reviewer examines medical documents to ensure accuracy and completeness. The job description includes overseeing and reviewing patient records and insurance paperwork. A well-drafted Clinical Reviewer Resume mentions the following core duties and responsibilities – conducting audits on all medical records, reviewing data to ensure the accuracy of the record, assessing the quality of patient care, reviewing and auditing medical records, checking for missing and incorrect documentation, coordinating in-service meetings and educating the medical staff on proper documenting procedures; and issuing citations to medical staff members if needed.
The most common requirement for the Clinical Reviewer post includes the ability to stay abreast of new Coding, government, and insurance guidelines; the ability to work in a highly computerized environment, strong professional image, negotiation skills, call management skills, and the ability to adhere and participate in the company’s mandatory HIPAA privacy program and practices. To enter this field, aspirants can start with an Associate of Applied Science in Health Information Technology.
Objective : As a Clinical Reviewer, responsible for performing medical record reviews to determine the quality of care; identifying quality issues, and assures compliance with medical record standards and regulatory mandates.
Skills : Group Facilitation, Individual Counseling, Case Management, Patient, Family And Community Education, Insurance.
Description :
Provided care across three states in nine geographic regions.
Ensured the behavioral health patients at the Proctor location are authorized for services.
Assisted in the Patient Advocate office as well.
Built and maintained rapport with various insurance reviewers in order to obtain authorization for treatment for the Addiction Recovery Center and for the Inpatient Senior Behavioral Health Unit.
Sent in medical records to appeal the denial of services and have obtained further authorization this way, thus bringing in more money to the company.
Responsible for auditing as well as validating internal audit results and/or corrective action plans.
Conducted ongoing activities that monitor established quality of care standards in the participating provider network and care managers.
Experience
2-5 Years
Level
Executive
Education
GED
Clinical Reviewer Resume
Summary : Highly skilled career Clinical Reviewer professional with more than 35 years of combined practical experience in HEDIS medical review with onsite abstraction from medical offices hospital, home, rehabilitation, 24/7 triage, disease management, utilization review, and telephonic care environments. Currently licensed in Virginia, a compact state, as well as in the non-compact states.
Skills : Quality Assurance, Case Management, Provider Relations, Utilization Review.
Description :
Provided clinical documentation review and chart review in an acute care setting, for units ranging from 15-25 beds daily, within the scope of practice of said job description.
Professionally communicated findings to all necessary parties participating in the individual's patient plan of care (POC).
Quickly assessed current patient census, prioritized and alerted proper personnel to potential denials or problems in the recommended treatment plan.
Successfully assigned DRGs to the Medicare population hospital-wide, utilizing anatomy and physiology knowledge, along with ICD-9 coding principles, for the proper utilization of healthcare services in the most appropriate setting.
Assisted in the implementation of Accommodation Code (AC) changes for the PCU unit, utilizing Interqual criteria for appropriateness of the level of care.
Performed timely and complete clinical reviews, via phone or fax, using persistent and persuasive communication skills.
Participated and contributed to interdisciplinary team meetings when applicable.
Experience
10+ Years
Level
Senior
Education
BS
Clinical Reviewer Resume
Objective : As a Clinical Reviewer, responsible for Establishing a strong record of achievements and career growth as a registered nurse with leadership, strong communication, organizational and interpersonal skills throughout my career as a pediatric and community health nurse. Offer a dedicated work ethic combined with a proven ability to adapt to changing environments and patient populations.
Skills : Microsoft Office, Interqual, Quality Improvement, Leadership, Project Management.
Description :
Responsible for reviewing and analyzing pre and post-pay complex health care claims from a medical perspective.
Made decisions concerning the validity of health care claims and levels of payment by Medicare and Medicaid Services (CMS) and within Novitas.
Performed some level of educational activities in the provider community.
Led specialty committees and contribute to the establishment and revision of policy and procedure guidelines for the department.
Identified quality-related problems and notify management appropriately.
Recommended process improvements designed to improve accuracy, timeliness of processing, and/or eliminate manual effort.
Reviewed provider treatment records against clinical and procedural established standards.
Experience
2-5 Years
Level
Junior
Education
G.E.D
Clinical Reviewer Resume
Headline : Dedicated Clinical Reviewer with specialty experience in psychiatric/mental health nursing. Developed strong psychiatric-evaluation and treatment-planning skills through recent job with KEPRO as a clinical reviewer for past 2 years. Handling customer related issues, provider's issues with eligibility criteria and related topics of concern.
Skills : Medication Administration, Asthma Education, Diabetes Education, CAD/CHF Education, Assessments, Home Health, Need CPR Recertification,.
Description :
Reviewed requests for psychiatric inpatient/outpatient services under the Medicaid contract.
Accomplished one full year of service with Magellan, did meet several benchmarks in productivity, was dependable, and worked abundant overtime.
Used Greeting people by phone, greeting teammates, speaking with clients and providers of services at the desk.
Managed the direct patient care appeals process.
Assumed primary responsibility and accountability for the case management of all patient care that has been denied for no precertification, including outpatient procedures.
Served on Professional Development Committee Proactive auditing to ensure proper patient status.
Responsible for reviewing clinical records for service recipients in the Waiver Program (Developmental Disability, Serious Emotional Disturbance.
Experience
5-7 Years
Level
Executive
Education
MS
Clinical Reviewer Resume
Objective : Clinical Reviewer with 2 years of experience in working collaboratively with Fidelis Care New York providers and educates them on all aspects of medical record review criteria including QARR/HEDIS; conducting member and/or provider telephonic outreach when needed.
Skills : Management, Medical Terminology, Phlebotomy.
Description :
Conducted Post Payment Review/Utilization Review of records of patients receiving Medicaid Personal Care Services (PCS) from home healthcare agencies documenting compliance/noncompliance with state and federal laws.
Results utilized by NC Division for Medical Assistance to adjust payments made to home health agencies.
Performed Inter-Rater Reliability (IRR) audits.
Developed and implemented an orientation program for new staff members in conducting clinical reviews.
Developed Audit Tools for the Community Alternatives Program for Children (CAP/C) and the Community Alternative Program for Disabled Adults (CAP/DA).
Completed a 10-hour online Utilization Management course.
Advanced from temporary to a permanent position.
Experience
2-5 Years
Level
Executive
Education
GED
Clinical Reviewer Resume
Objective : Highly qualified Clinical Reviewer with experience in the industry. Enjoy creative problem solving and getting exposure on multiple projects, and would excel in the collaborative environment on which your company prides itself.
Skills : MS Office, Multitasking, Communication.
Description :
Responsible for performing HEDIS record reviews as well as Adult and Pediatric Medical Record Reviews.
Performed as Lead for academic detailing to maintain ongoing telephonic and on-site visits to providers.
Stayed abreast of changes in Fidelis Performance Management measures and systems and changes in clinical guidelines.
Performed reviews of medical records and standards.
Posted completed review reports with the number of records reviewed and quality issues noted.
Collaborated with providers and adhere to clinical standards of care to ensure appropriate outcomes; practice and adhere to departmental, state, and national guidelines.
Educated providers on clinical guidelines and QARR/HEDIS measures.
Communicated in an efficient, effective, and friendly manner with providers, internal, and external staff.
Experience
2-5 Years
Level
Junior
Education
GED
Clinical Reviewer Resume
Headline : Clinical Reviewer with 3 years of experience in Providing screening related reports and participant statistics to the Contract Officer Representative (COR) of the OCD recruitment, advertising, remuneration, and outreach contracts.
Participated in professional societies to maintain professional and technical knowledge.
Distributed and maintained patient medical information while following HIPPA guidelines Processed information given by patients, doctors, and pharmacy.
Provided medical review of documents (assess clinical safety and performance data and ensure anatomic, physiologic, and clinical accuracy)
Conducted comprehensive, systematic searches of published medical literature.
Experience
5-7 Years
Level
Executive
Education
MS
Clinical Reviewer Resume
Headline : Clinical Reviewer with 5 years of experience in Coordinating phone and in-person screening tasks and delegate screening responsibilities to other screening staff in order to support the needs of studies and help the screening process be efficient across Branches.
Skills : Case Management, Exceptional Listener and Communicator, Strong Analytical, Computer-Literate, and Goal-Driven Leader.
Description :
Served as a clinical reviewer for insurance payor sources.
Reviewed and analyzed medical records for reimbursement purposes for all medical specialties (i.e., obstetrics and gynecology, surgery, cardiology.
Conducted prior authorizations activities and referral management activities.
Assessed medical necessity by screening available information against established criteria.
Contacted beneficiary and/or provider to obtain or clarify medical information as necessary.
Provided interpretation and analysis of clinical and non-clinical data pertinent to scientific communications projects (e.g., literature reviews, Clinical Evaluation Reports, and clinical study reports).
Wrote and/or direct the preparation of clear and effective documents.
Experience
5-7 Years
Level
Executive
Education
Associate In Nursing
Clinical Reviewer Resume
Objective : Seeking a Clinical Reviewer position with an outstanding career opportunity that will offer a rewarding work environment along with a winning team that will fully utilize management skills.
Triaged calls to determine call type and transfer to the appropriate department as necessary.
Experience
2-5 Years
Level
Executive
Education
BS
Clinical Reviewer Resume
Objective : A detailed-orientated Clinical Reviewer professional with the ability to successfully manage full lifecycles of client meetings and programs. Highly organized with excellent interpersonal and customer service skills, problem-solving, thrives under pressure, is an enthusiastic and dedicated employee with uncompromised integrity, strong work ethic.
Skills : Detail-Oriented, Communication, MS Office.
Description :
Refaxed letters to providers and facilities, as necessary.
Ensured accurate documentation of calls.
Identified requests for escalation/complaints and escalate accordingly.
Routed identified issues to the appropriate site, as necessary.
Managed calls efficiently and effectively.
Owned problem through to resolution on behalf of the member/provider/facility in real-time or through comprehensive and timely follow-up with the member /provider/facility.
Researched complex issues across multiple databases and work with support resources to resolve the inquiry.
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