Clinical Reviewer
- Are you an experienced Clinical Reviewer looking for a new challenge?
- Do you value care management and quality improvement?
- Are you motivated, energetic, and excited to become part of the Kepro team?
If so, you might be our next new team member!
Who we need:
The Clinical Reviewer utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision-making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.
Why us?
Kepro is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting.
People Focused. Mission Driven.
Shape the future of healthcare with us. We are mission driven to improve lives through healthcare quality and clinical expertise.
We do this through our people.
At Kepro, you can do meaningful work that makes a real difference for the lives of individuals across the country. We are an organization that cares deeply about our employees and we provide the training and support to do the best work of your career.
Benefits are a key component of your rewards package at Kepro. These benefits are designed to provide you and your family additional protection, security, and support for both your career and your life away from work. They are comprehensive and fit a variety of needs and situations. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more.
What you’ll do:
- Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
- Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence.
- Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties.
- Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.
- Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
- Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
- Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
- Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following KEPRO policies, procedures and guidelines
- Actively cross-trains to perform duties of other contracts within the KEPRO network to provide a flexible workforce to meet client/consumer needs.
- Other duties as assigned
- The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.
What you’ll need:
Qualifications
- Active unrestricted RN applicable State and/or Compact State clinical license per contract requirements.
- Graduation from an accredited Diploma, Associates Degree or Bachelor’s Degree Program
- Knowledge of InterQual criteria.
- Knowledge of current NCQA/URAC standards strongly preferred.
- Medical record abstracting skills required.
- Knowledge of the organization of medical records, medical terminology, and disease process required.
- Strong clinical assessment and critical thinking skills required.
- Excellent verbal and written communication skills required.
- Ability to work in a team environment.
- Flexibility and strong organizational skills needed.
- Must be proficient in Microsoft Office and internet/web navigation
- Minimum two years of clinical experience in an acute or med-surgical environment required.
- Minimum of one year UR and/or Prior Authorization or related experience.