Clinical Review Specialist

HCA Saint Louis , MO 63150

Posted 5 months ago

MAJORRESPONSIBILITIES
1.Performs TAR reviews and completion of TAR requestsaccording to Medi Cal format and deadlines
2.Performs Medi Cal clinical medical file review ofhospital documentation for necessary clinical treatment and patient severity ofillness to warrant admissions and continued acute inpatient level of care
3.Performson line documentation of clinical justification for hospital stays and prescreening of files to determine if Appeal is warranted.
4.Documentsclinical justification for Appeal requests
5.Conducts clinical review of casesthat do not meet criteria
6.Performs clinical intake andreviews cases according to the policies and procedures of Parallon.
7.Collects and enters confidentialinformation ensuring the highest level of confidentiality in all areas.
8.Maintains written documentationaccording to Parallon's documentation policy
9.Provides ongoing to TAR related to Parallon's Clinical Review process

Assistsin the orientation and training of new clinical TAR staff in department.
10. Participates and understands scopeof responsibility in all ongoing of the TAR Process.
11. Knowledge of care management plans and servicesin order to implement that knowledge in a clinical in-patient setting.
12. Knowledgeof care management plans and services in order to implement that knowledge in aclinical setting.
13. Ability to use independent judgment related tomedical record review.

QUALIFICATIONS

  • Preferred LVN from an accredited school of nursing

  • PreferredCurrent, active California LVN license

  • 2-3 years experience in acute care environment

  • 3 years previous utilization management experience in a managed care

and/or hospital setting

  • Computer proficiency

  • An associate or bachelor's degreein nursing or a hospital-sponsored diploma

Program.

  • Knowledgeand proficiency of established clinical standards and

guidelines with Medi-Cal

  • Goodorganizational skills preferred

  • Experience in both nursereview and assisting with the utilization review

appeals process.


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Clinical Review Specialist

HCA