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CHS Medical Case Reviewer in Clearwater, Florida

The Medical Record Reviewer executes reviews and clinical audits as a part of the Company's clinical compliance audit and Quality Assurance controls program. The Medical Record Reviewer executes clinically-related (i.e. medical record and related treatments) audit procedures to assess compliance-related controls to safeguard company resources and ensure the effectiveness and efficiency of clinical treatment and document compliance. The Medical Record Reviewer, in conjunction with the Director of Quality/Risk Management and the Medical Staff, makes recommendations for improvement of controls in processes to ensure risk management, ensures control and regulatory standards are being followed as intended, and will enable the objectives and goals to be met.

Essential Duties and Responsibilities:

  • Ability to review and analyze a variety of medical/clinical records to discern when symptoms, diagnosis, or treatment were initiated and summarize findings in plain language quickly and competently.

  • Understand and apply health plan benefits to medical records to ensure claims are within plan benefits.

  • Ability to navigate and work within multiple computer systems.

  • Review Medical records

  • Review Itemized Bills

  • Reconciliation of Claims Image

  • Escalate priority issues

  • Document all activities and call information according to standard operating procedures

  • Review medical records and assess for pre-existing condition and relevant exclusions on the policy

  • Policy review and research

Other Responsibilities:

  • Adheres to the policies and procedures of Company

  • Maintains strict confidentiality of client, company and personnel information

  • Demonstrates a strong commitment to the mission and values of the organization

  • Adheres to company attendance standards

  • Performs other duties as assigned

Supervisory Responsibilities: None

Competencies:

  • Strong organizational, interpersonal and motivational skills

  • Excellent written and verbal communication skills

  • Detail oriented, organized, independent

  • High level of reasoning and analytical skills

  • Ability to multi-task and work independently

  • Ability to read, analyze and interpret medical records, claims files and underwriting reports.

  • Must have strong analytical, organization and decision-making skills and a business orientation.

Qualifications:

  • Three to five years of clinical licensed (LPN or RN) experience.

  • Hospital experience strongly preferred.

  • Must have an in-depth knowledge of the case management process.

  • Must be familiar with ICD-10 and CPT codes

  • Background in medical insurance case management preferred.

Certificates, Licenses, Registrations:

  • Current RN or LPN licensure in FL, mandatory.

Computer Skills:

Proficiency using software programs such as MS Word, ACCESS, PowerPoint, Excel and Outlook, Electronic Health Records.

Environmental Factors/Physical Demands:

Work is performed in an office and onsite facility care environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.

ID: 2021-2137

External Company Name: People Premier

External Company URL: chsamerica.com

Street: 13600 Icot Blvd

Responsibilities (Text Only): Essential Duties and Responsibilities: - Ability to review and analyze a variety of medical/clinical records to discern when symptoms, diagnosis, or treatment were initiated and summarize findings in plain language quickly and competently. - Understand and apply health plan benefits to medical records to ensure claims are within plan benefits. - Ability to navigate and work within multiple computer systems. - Review Medical records - Review Itemized Bills - Reconciliation of Claims Image - Escalate priority issues - Document all activities and call information according to standard operating procedures - Review medical records and assess for pre-existing condition and relevant exclusions on the policy - Policy review and research Other Responsibilities: - Adheres to the policies and procedures of Company - Maintains strict confidentiality of client, company and personnel information - Demonstrates a strong commitment to the mission and values of the organization - Adheres to company attendance standards - Performs other duties as assigned Supervisory Responsibilities: None

Qualifications (Text Only): Competencies: - Strong organizational, interpersonal and motivational skills - Excellent written and verbal communication skills - Detail oriented, organized, independent - High level of reasoning and analytical skills - Ability to multi-task and work independently - Ability to read, analyze and interpret medical records, claims files and underwriting reports. - Must have strong analytical, organization and decision-making skills and a business orientation.

Qualifications: - Three to five years of clinical licensed (LPN or RN) experience. - Hospital experience strongly preferred. - Must have an in-depth knowledge of the case management process. - Must be familiar with ICD-10 and CPT codes - Background in medical insurance case management preferred.

Certificates, Licenses, Registrations: - Current RN or LPN licensure in FL, mandatory.

Computer Skills:

Proficiency using software programs such as MS Word, ACCESS, PowerPoint, Excel and Outlook, Electronic Health Records.

Environmental Factors/Physical Demands:

Work is performed in an office and onsite facility care environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.

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