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Clinical Review Specialist

Location: Gamma Dr. Pittsburgh, PA

Description

Manages submission processes where authorization, re-authorization, and utilization processes have been deemed to be higher risk. Works in collaboration with the National Accounts, Sales, and internal Reimbursement teams to meet plan requirements and develop new processes that may meet plan and ZOLL needs more effectively.

Essential Duties and Responsibilities:

  • Responsible for conducting pre-qualification of potential patients and concurrent appropriate use review for patients
  • Facilitates product use by knowing, understanding, correctly interpreting, and accurately applying criteria such as Medicare Local Coverage Determination, Sudden Cardiac Death Primary Prevention Protocol, and New York Heart Association Classification
  • Tracks and reports trends of inappropriate utilization of resources or quality issues to supervisor
  • Understanding of clinical and care management process
  • Knowledge of medical necessity criteria (InterQual and Milliman guidelines) to understand insurance requirements for authorization reviews, insurance process for approvals, and structure of authorization flow
  • Excels in abstracting pertinent information from medical record and summarize key points with speed, accuracy, and effectiveness

Supervisory Responsibilities: None

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.

  • Demonstrate critical thinking and oral and written communication skills to support review findings
  • Demonstrate ability to develop and implement new processes to address issues as they arise
  • Ensure consistent application of the clinical review processes for all functional components
  • Able to work independently with a high degree of attention to detail and reliable decision-making abilities.
  • Show attention to detail and thoroughness in review of medical documentation.
  • Provides structure for clinician to clinician consultations where requested throughout Reimbursement process
  • Proven organization, time management and prioritization skills
  • Interacts positively with team members and available to provide coaching/feedback to team members.
  • Critical thinking and assessment skills are required
  • Some travel may be required.
  • Performs other duties as assigned by Management.

Educations and/or Experience:

  • Nursing Degree required
  • Nursing license required
  • Cardiovascular industry or clinical experience preferred
  • Proficient in Microsoft Word, Excel, PowerPoint program
  • High level of comfort with computers and flexibility and aptitude for learning new skills and software applications as needed
  • Excellent organizational skills with attention to detail.
  • Knowledge of medical terminology

Language Skills
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization. Mathematical Skills Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.

Reasoning Ability
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Physical Demands
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 may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 25 pounds.

Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually quiet.

 

ZOLL is an Equal Opportunity Employer - minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity.





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