Clinical Review Specialist

Commonwealth of VA Careers; Staunton (VA); On-site; USD 77,000 - 107,000; Full time

Job summary

Commonwealth of VA Careers is seeking a Clinical Review Specialist to evaluate delivery of care through Utilization Review processes and coordinate data collection and reporting. The role requires nursing expertise in inpatient psychiatric care, knowledge of Medicaid regulations, and the ability to communicate with clinicians, administrators, and external agencies.

Join a state agency committed to quality and compliance.

Qualifications

• Licensed RN with ASN and current licensure.
• In-depth knowledge of inpatient psychiatric treatment and Medicaid regulations.
• Experience with HIPAA and compliance requirements.
• Ability to analyze complex clinical documentation for quality improvement.
• Strong written and oral communication with clinicians, administrators and external agencies.
• Proficient basic computer skills (typing) and MS Office suite.

Responsibilities

• Evaluate delivery of care through Utilization Review processes.
• Data collection, analysis and reporting.
• Communicate with Medicaid, private payers and regulators.
• Manage employee health responsibilities.

Skills

Psychiatric nursing expertise

Inpatient psychiatric care knowledge

HIPAA compliance

Clinical documentation analysis

Effective communication

MS Word & MS Excel

Education

ASN and RN license

Tools

MS Word

MS Excel

Job description

Title: Clinical Review Specialist

State Role Title:Health Care Compliance Spec II

Hiring Range: Starting Pay from $77,234 - $106,583 per year

Pay Band: 4

Agency: Dept Behavioral Health/Develop

Location:Comm Ctr for Child & Adoles

Agency Website:https://dbhds.virginia.gov/facilities/ccca/

Recruitment Type: General Public - G

Job Duties

• A. Evaluate delivery of care through Utilization Review (UR) Process
• B. Data collection analysis and reporting.
• C. Communicate with Medicaid and private insurance third party payers and regulatory agencies.
• D. Employee Health responsibilities

Minimum Qualifications

• Psychiatric/clinical nursing expertise.
• Demonstrated knowledge of inpatient psychiatric treatment and documentation requirements to meet State and Federal Medicaid regulations.
• HIPPA and Compliance regulations
• Skilled in analyzing complex clinical documentation to identify discrepancies and recommends improvements, facilitating ongoing quality enhancement efforts
• Ability to communicate effectively, orally and in writing with clinicians, administrators, and patients, patients’ families, and external agencies.
• Basic computer proficiency with typing, and knowledge of MS Word, and MS Excel
• Must possess ASN and active RN license.

Additional Considerations

• BSN Preferred
• Clinical delivery experience in an inpatient psychiatric setting required
• Prior experience in data management and analysis, utilization review, Medicaid and third party commercial insurances preferred.
• Experience with medical reviewers preferred
• Experience with Joint Commission standards preferred.

Contact Information

Name: John Lee

Phone: [phone]

Email: [e-mail]

A fingerprint-based criminal history check and reference checks are required for the selected candidate for this position. Under Virginia Code §37.2-314 and 37.2-408.1, the Department of Behavioral Health and Developmental Services is prohibited from employing or using as volunteers, persons who have been convicted of specific “barrier” crimes or persons who may be the subject of pending “barrier” charges.

DBHDS facilities are no longer required to ensure that all staff members are vaccinated against COVID-19. However, facilities encourage and educate staff on the benefits, and continue to offer COVID-19 vaccination programs to staff, residents/clients. Employees may be required to disclose immunization status for purposes of infection prevention and/or management of outbreaks. Upon acceptance of a job offer, new recruits will be asked to disclose their vaccination status (and for those fully vaccinated, proof of vaccination) during the pre-employment process. If you have any questions, contact the Office of Human Resources.

Commonwealth’s Alternate Hiring Process: In support of the Commonwealth’s commitment to inclusion, individuals with disabilities are encouraged to apply through the Commonwealth Alternative Hiring Process. To be considered for this opportunity, applicants will need to provide their Certificate of Disability (COD) provided by a Certified Rehabilitation Counselor with the Department of Aging and Rehabilitative Services (DARS). Veterans are encouraged to answer Veteran status questions and submit their disability documentation, if applicable, to DARS, to get their Certificate of Disability. To obtain a Certificate of Disability go to: https://www.vadars.org/drs/cpid/PWContact.aspx, or call DARS at 800-552-5019.

Reasonable accommodations are available to persons with disabilities during the application and/or interview process per the Americans with Disabilities Act. Contact Human Resources at [phone] for assistance.

DBHDS is an equal Opportunity Employer. Employment opportunities are open to all regardless of race, sex, color, national origin, religion, sexual orientation, gender identity, age, veteran status, political affiliation, genetics, or disability. Minorities, Individuals with Disabilities, Veterans, and people with National Service experience are encouraged to apply. EEO/AA/TTY.

In support of the Commonwealth’s commitment to inclusion, we are encouraging individuals with disabilities to apply through the Commonwealth Alternative Hiring Process. To be considered for this opportunity, applicants will need to provide their AHP Letter (formerly COD) provided by the Department for Aging & Rehabilitative Services (DARS), or the Department for the Blind & Vision Impaired (DBVI). Service-Connected Veterans are encouraged to answer Veteran status questions and submit their disability documentation, if applicable, to DARS/DBVI to get their AHP Letter. Requesting an AHP Letter can be found at AHP Letter or by calling DARS at 800-552-5019.