Specialist Clinical Review

This is a casual position. A casual is a non-benefit eligible position that is not guaranteed any hours, but can pick up open shifts.

Purpose of Job

The Specialist Clinical Review ensures hospital patients receive the care they need at the most appropriate admission status, while managing costs and making the best use of available resources. They also work to manage denial avoidance by confirming accuracy with compliance agencies (DNV, CMS, QIO, Etc.).

Job Functions

1. Conducts admissions and concurrent stay reviews for medical necessity by utilizing established Utilization criteria.
2. Conduct clinical review for third party payers, providing information for third party payers as requested.
3. Work collaboratively with Clinical Documentation Integrity to determine appropriate length of stay (GLOS).
   1. Share GLOS at discharge planning meeting when > 2 days over established GLOS
   2. Monitor and report delays and variances in length of stay
4. Attend and collaborate at the Discharge Planning meeting, participating in sharing information that may impact discharge plans. Including insurance coverage, admission status, and Medicare regulations that impact patient stay.
5. Communicates effectively and confidently with Providers, Social Workers, and Nurses to ensure comprehension of admission status requirements.
6. Optimizing reimbursement to avoid payer denial.
7. Serve as a liaison and subject matter expert between Patient Financial Services, payers, and providers.
8. Monitor patient acuity and notify appropriate staff of changes, including admission status changes.
9. Reviews and supports Discharge Team and facilitates discharges in complex cases.
10. Documents continued need for inpatient level of care at day 7 and contacts the physician to document continued need of inpatient care at day 20. Ensures that physician documentation is in the patient chart.
11. Assist with patient education related to Medicare admission status requirements, when requested or needed.
12. Performs other duties as assigned.

Minimum Education/Work Experience

• Graduate of an accredited school of nursing
• Three years of experience in medical or surgical nursing
• Recent clinical experience

Knowledge/Skills/Abilities

• Demonstrated critical thinking and decision making
• Ability to work autonomously and as a team
• Ability to respond appropriately to unpredictable situations and diverse patient populations
• Ability to maintain skills and familiarize self with new equipment and procedures as the need arises
• Ability to navigate multiple applications
• Comprehensive knowledge of Microsoft systems
• Ability to meet and maintain the necessary background checks as aligned with position function
• Ability to communicate in the English language for effective written and verbal correspondence in order to complete job functions as mentioned above

License/Certifications

• Current professional nurse licensure in Minnesota or if licensed in another state, a permit from the Minnesota Board of Nursing while the license application is in process

Preferred Qualifications

• Previous utilization review experience

Link to Employee Health Physical Demands

Compensation

Many factors are taken into consideration when determining compensation such as: the requirements of the position, experience, education, knowledge, and skills along with location and internal equity. Pay listed does not include any shift, weekend, or other differentials.

Benefits

Ridgeview strives to provide comprehensive and market competitive benefits to meet the needs of our employees and their families.

Click here to view the benefits available.