Determines if bills are payable or if additional information is needed, Works one on one with staff not meeting quality expectations to re-train as needed, Communicates daily with Medical Audit Nursing Supervisor and Manager, Minimum three (3) years of experience in Clinical Review as Provider Reimbursement Specialist, Minimum 4 year degree and/or equivalent experience, Minimum 4 year Healthcare/Health Plan experience, Minimum 2 years of team or organizational leadership experience, Evaluate HP work history dates, sites and settings to identify gaps in accuracy and eligibility in order to request necessary information & to assign appropriate skill set on new applications and reapplications, Identify process improvement opportunities by evaluating processes and guidelines in order to propose value-added solutions that increase volume, turnaround time and/or accuracy, Review convictions, license disciplinary actions, references, PLI (professional liability insurance) history and other derogatory information to determine whether to make a decision on continued eligibility or to escalate to appropriate internal decision makers, Processes pre-start cancels, communicates to all stake holders and investigate HPs incurring pre-start cancels to determine eligibility for future assignments; escalating when necessary to Clinical Manager/Director or Clinical Risk Review Committee, Prioritize incoming review requests by evaluating business need and urgency in order to increase speed to market, Enters, maintains and communicates with team members as appropriate for CLNs with requirement for Medical Release or Work Place Accommodation, Generates and manages reports for Clinical Services Department, Manages basic Checkster administrative support, Reviews and processes returned evaluations and maintains biennial evaluations according to established protocol for updates, Graduation from an accredited school of health information management and four (4) years of relevant experience; or a combination of experience and education, Knowledge in medical terminology, anatomy and physiology, Three (3) years of experience working in a hospital, medical group, or health plan environment managing clinical review for medical necessity and document integrity; and/or two (2) years in case management experience, clinical documentation improvement, clinical denials management, clinical review, Experience with LCDs, NCDs, PEPPER, CERT, QIOs, Knowledge of CMS and other payer documentation, compliance, reimbursement and coding requirements, Knowledge of federal, state, and local billing and research compliance regulations, Ability to assess clinical systems, such as identifying gaps between services required and services available, Experience with program evaluation through outcomes measurement, including principles of continuous quality/performance improvement, use of benchmarks and analysis of trends, and other means to create understanding of current condition and return on investment, Proficiency in Information Systems, databases, and in the use of technology and computer programs including MS Office (Word, Excel, Power Point, Outlook, etc. Great! Wednesday, January … Who could ask for anything more? Provides feedback to manager to ensure work is in compliance, Acts as resource to PRS staff as content expert in reviewing claims for emergency benefit, Participates in supervisor meetings with Northern and Southern CCA, HR and Clinical Review, Works on special projects that require knowledge of multiple systems, Responsible for training new PRS staff to review claims based on routing criteria. If you wish to chat first to determine if we can assist you in the development of a spectacular IT Manager resume, just call our toll-free number at 888-291-9821. "The Resume Review has an outstanding sense of what details should stand out and which attributes get the most attention and positive feedback, and then draw those items out in a visually appealing format. Review our various resume writing category options and you can get started immediately. ), Ability to construct grammatically correct correspondence and reports using standard medical terminology, Proven analytical and problem solving skills, ability to problem solve, engage in abstract thought, and successfully manage conflicts. My resume stood out and was integral to me securing my new sales position in the Midwest. Rn Clinic Specialty Lead Lakeside Women s Health Clinic M F New Hire Bonus Resume Examples & Samples Administer medications by oral, intramuscular, subcutaneous, intradermal routes, IV Educate patient and/or family on prescribed treatment regimens 3,253 reviews from Cleveland Clinic employees about Cleveland Clinic culture, salaries, benefits, work-life balance, management, job security, and more. Please enter the code we just sent to Search . Ensures data accuracy according to departmental operating procedures, Knowledge of care management plans and services in order to implement that knowledge in a clinical setting, Performs TAR reviews and completion of TAR requests according to Medi Cal format and deadlines, Knowledge of care management plans and services in order to implement that knowledge in a clinical in-patient setting, Performs on line documentation of clinical justification for hospital stays and pre screening of files to determine if Appeal is warranted, Maintains a working mastery of industry-standard utilization review criteria (ie: Interqual), coverage guidelines, and payer medical policies, Demonstrates knowledge of governmental, managed care, and commercial denial/appeal policies, Notifies department leadership regarding patterns/trends, Together works with department leadership and other Denial Management Team Members to develop and facilitate processes which promote job effectiveness and efficiency, Actively educates and collaborates with other hospital staff and associates at the SSC regarding denial/appeal strategies, Serves as a clinical resource to other associates at the SSC, Performance – maintain performance standards that ensure the department is operating at peak proficiency and that established goals are consistently being met, Work performed is done in conjuncture with the patient's provider and the care coordinator to complement the office-based clinician's workflow, The work performed is to complement the office based clinician's work, Participate in regularly scheduled staff development trainings to maintain and improve personal knowledge base of various chronic diseases, Assists with clerical duties as assigned i.e. Clinic Resume Sample 4.8. 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I received an email notification from the federal government exactly a week from the date that I submitted my resume an am currently going through the hiring process. ), Coordination and/or management of Online Incident Reporting Systems experience, Reviews patient data in accordance with the Manual Data Review Plan in the DVM, Uses medical knowledge to clarify and resolve issues with clinical data (e.g. Employers . May include doing pre-procedure phone calls to patients and/or physician offices to obtain information Of the 300+ clients I've sent to this firm, they have boasted a 100% satisfaction rate. iHire sent many great jobs but at least… iHire sent many great jobs but at least half weren't even close to what I was seeking. In addition, bring your resume in for a review during our Career Studio Hours (for current eligible students only) Home; Pursue Your Goals; Resume Samples Upcoming Programs. Search form. 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