Clinical Review Specialist (31389)

GI Alliance; Southlake (TX); On-site; USD 80,000 - 100,000; Full time

Job summary

GI Alliance is looking for an experienced Clinical Review Specialist in Southlake, Texas. This role involves clinical oversight, ensuring compliance with payer requirements, and collaborating with multiple stakeholders. The ideal candidate has 5+ years of nursing experience, preferably with infusion knowledge.

You will work closely with various teams while documenting clinical information accurately and timely. Join a diverse and inclusive work environment committed to quality patient care and excellence.

Qualifications

• Minimum of five (5) years of relevant nursing experience.
• Minimum one (1) year of case management and/or utilization review.
• Infusion experience preferred.

Responsibilities

• Provide clinical oversight to ensure completeness and accuracy of prior approvals.
• Collaborate with stakeholders to obtain needed information.
• Document necessary information in appropriate electronic tools.

Skills

Knowledge of clinic policies and procedures

Knowledge of medical terminology and insurance practices

Skill in written and verbal communication

Ability to establish and maintain effective working relationships

Education

Nursing Degree or diploma from an accredited institution

LVN or RN in good standing

Tools

Standard office equipment

Job description

GI Alliance is seeking an experienced Clinical Review Specialist.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.

Position purpose

Works collaboratively with multiple stakeholders in Infusion Operations to ensure required clinical information is received and reviewed in the infusion intake workflow based on payer and regulatory requirements and lead and manage the appeal process as required.

Responsibilities

• Provides clinical oversight and review to ensure the completeness and accuracy of prior approvals based on payer requirements is achieved on all assigned patients and locations.
• Attention to detail regarding required documentation and follow up with outstanding information on a timely basis
• Collaborates with practice staff, physicians, patients, payers and infusion department in obtaining needed information to complete job tasks and responsibilities
• Consistently identifies and tracks information on referrals/ appeals as needed
• Documents all necessary information in appropriate electronic tools, communicates with appropriate stakeholders timely and coordinates peer to peer communication as per recommended timelines.
• Completes Letters of Medical Necessity or other required clinical documents to assist with the intake and appeal process
• Completes all reviews within department established policies and best practice standards.
• Prioritizes incoming work appropriately and timely and communicates to all required stakeholders as appropriate at each step of the workflow
• Serve as a clinical resource to non-clinical staff
• Assist with quality audits and maintain accurate reports.
• Actively participates in the department’s performance improvement initiatives
• Perform other duties as assigned

Qualifications

Education: Nursing Degree or diploma from an accredited institution required. LVN or RN in good standing required.

Experience: Minimum of five (5) years of relevant nursing experience. Minimum one (1) year of case management and/or utilization review in acute care or insurance related role.

Other Qualifications: Infusion experience preferred.

Performance Requirements

• Knowledge of clinic policies and procedures.
• Knowledge of medical terminology and insurance practices.
• Knowledge of computer programs and applications.
• Knowledge of CPT and ICD-10 coding.
• Knowledge of managed care, Medicare, and Medicaid guidelines.
• Skill in written and verbal communication.
• Ability to work effectively as a team member with physicians and other staff.
• Ability to flexibly respond to changing demands.
• Ability to plan, organize, prioritize and complete work independently
• Ability to sort and file materials correctly by alphabetic or numeric systems.
• Ability to establish and maintain effective working relationships with patients, employees, and the public.
• Prior experience with clinical review, case management, utilization review
• Experience managing patient issues professionally.

Equipment Operated

Standard office equipment including computers, fax machines, copiers, printers, telephones, etc.

Work Environment

Work requires hand dexterity for office machine operation, stooping and bending to files and supplies, mobility to complete errands, or sitting for extended periods of time. Occasionally lifting files or paper weighing up to 20 pounds. Occasionally work environment may be very stressful.

Mental/Physical Requirements

Normal office environment. May view computer screens for long periods of time. Occasional evening or weekend work.

GI Alliance is an Equal Opportunity Employer. We are committed to creating an inclusive, welcoming, and equitable work environment. Our company values and celebrates the diversity of our physicians, staff and patients. We firmly believe our service is greatly enriched by our diversity of thought, experience, perspective, culture, and background.

Please Note: All job offers are contingent on the successful completion of pre-employment criminal history check.

EEO/AA-M/F/disabled/protected veteran