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. KEPRO is seeking resumes for a highly experienced professional.

Clinical Reviewer

Summary Description

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.

Accountabilities

• 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.

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.

Qualifications

• Active unrestricted RN license.


• Graduation from an accredited Diploma, Associates Degree or Bachelor’s Degree Program.

Knowledge, Skills, Abilities

• Knowledge of InterQual criteria strongly preferred.


• 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.

Experience

• 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.


• For BH Programs: Minimum 3 years direct behavioral/mental health experience in a clinical setting or other applicable State and/or Compact State clinical experience or license per contract requirements.

Mental and Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

KEPRO offers challenging careers, excellent benefits and opportunities for advancement. For consideration, please submit resume and cover letter with salary requirements. Only those candidates identified for an interview will be contacted. No Phone Calls Please. Visit our website at www.KEPRO.com for more information on the KEPRO Family of Companies.

EOE AA M/F/Vet/Disability

KEPRO is an Equal Opportunity Employer.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)

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