InterQual Specialist/Clinical Documentation Reviewer

Job Summary:

Responsible for conducting thorough reviews of clinical documentation to ensure accurate

and comprehensive representation of patient care and facilitate appropriate reimbursement for services

provided. Expertise in utilizing the InterQual criteria and knowledge of clinical guidelines will play a vital

role in ensuring compliance with regulatory standards and optimizing the hospital's revenue cycle.

Responsibilities:

1. Perform comprehensive reviews of clinical documentation to ensure accuracy, completeness, and

compliance with industry regulations, including InterQual criteria and other clinical guidelines.

2. Collaborate with physicians, nurses, and other healthcare professionals to obtain additional

documentation and clarification when necessary to support the accuracy and specificity of diagnoses

and procedures.

3. Evaluate medical records for appropriate utilization of resources and medical necessity, identifying

potential discrepancies or gaps in documentation.

4. Apply critical thinking skills and clinical knowledge to assess the severity and complexity of the

patient's condition, accurately assigning appropriate levels of care and severity of illness.

5. Identify opportunities for improvement in documentation practices and provide education and

feedback to physicians and other clinical staff to enhance overall documentation quality.

6. Collaborate with coding and billing teams to ensure appropriate reimbursement for services rendered,

including providing supporting documentation and rationale for medical necessity.

7. Stay updated on changes in industry regulations, payer requirements, and clinical guidelines,

incorporating them into the documentation review process as necessary.

8. Participate in quality improvement initiatives and audits related to clinical documentation and coding

practices, identifying trends and recommending appropriate corrective actions.

9. Maintain accurate and detailed documentation of review findings, outcomes, and communication with

healthcare providers.

10. Provide training and education to clinical staff on documentation best practices, including the use of

Requirements:

1. Bachelor's degree in nursing or a related healthcare field. Registered Nurse (RN) licensure is preferred

but not mandatory.

2. Minimum of 2 years of experience in a healthcare setting, with a focus on clinical documentation

improvement, utilization management, or related areas.

3. Strong understanding of InterQual criteria and clinical guidelines, with the ability to apply them

effectively to documentation review.

4. In-depth knowledge of coding systems (e.g., ICD-10-CM, CPT) and reimbursement methodologies

(e.g., DRGs, APCs).

5. Familiarity with regulatory requirements and industry standards related to documentation, billing, and

compliance (e.g., CMS guidelines, HIPAA).

6. Excellent analytical and critical thinking skills, with the ability to identify and address documentation

deficiencies and discrepancies.

7. Strong interpersonal and communication skills, including the ability to collaborate effectively with

interdisciplinary teams and provide education to healthcare providers.

8. Detail-oriented approach with a high level of accuracy in reviewing and interpreting medical records.

9. Proficiency in using electronic health records (EHR) systems and computerized documentation tools.

10. Professional certifications such as Certified Clinical Documentation Specialist (CCDS) or Certified

Professional in Healthcare Quality (CPHQ) are desirable but not mandatory.

Job Type: Full-time

Pay: From $15.00 per hour

Schedule:

• Day shift
• Night shift

Ability to commute/relocate:

• Lancaster, TX 75146: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Utilization review: 1 year (Preferred)

License/Certification:

• RN (Preferred)

Work Location: In person

Salary : $15