Clinical Reviewer Resume Sample
Tanner Gutkowski
70375 Goodwin Stravenue,
Chicago,
IL
+1 (555) 782 5923
Work Experience
Senior Appeals Clinical Reviewer
01/2018
-
PRESENT
San Francisco, CA
- Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices
- Identifies 100% of bariatric surgery patients for inclusion in the data registry
- Collects preoperative, intraoperative, 30-day postoperative, and long-term (6 month and annual thereafter) follow up data components for the program through effective utilization of the hospital medical record systems and through coordinated effort with individual surgeon office staff
- Responsible for accurate and timely entry of data into the program’s database. Maintain data integrity of Center for The American College of Surgeons’ Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database and enters data into MBSAQIP databases
- Integral role in helping educate providers and key healthcare personnel regarding clinical documentation integrity and the need for accurate and complete documentation in the health record
- Perform remote or on-site paper or electronic medical chart review in variable settings and for multiple purposes, as instructed
- Assess clinical aspects of medical record documentation to drive improvement and consistency in application across all lines of business
- Ensure strict confidentiality of financial and medical records
- Work directly with management to establish policies and procedures for continuous clinical documentation integrity
Clinical Reviewer
06/2011
-
12/2017
New York, NY
- Travel to clinics required
- Review all imaging cases in which clinical determinations cannot be made by the Initial Clinical Reviewer
- Discuss determinations with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request by phone or fax
- Provide clinical rationale for standard and expedited appeals
- Provide assistance and act as a resource to Initial Clinical Reviewers as needed to discuss cases and problems
- Participate in daily review of aggregate denials/appeals with appropriate staff/leaders
- Utilize medical review guidelines and parameters to assure consistency in the MD review process so as to reflect appropriate utilization and compliance with SBU?s policies/procedures, as well as URAC and NCQA guidelines
Initial Clinical Reviewer
02/2005
-
04/2011
Chicago, IL
- Ensure documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner
- Participate in on-going training per inter-rater reliability process
- Assist the Medical Director in research activities related to Utilization Management Information Systems (database development/outcomes reporting)
- Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and policies, procedures and criteria
- Utilizes medical review guidelines and parameters to assure consistency in the MD review process so as to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as URAC and NCQA guidelines
- Assists the Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support
- Refers all cases not meeting criteria to peer clinical review
- Converses with medical office personnel in order to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale
- Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plan's required timeframes
Education
Indiana Wesleyan University - Cleveland Education Center
2001 - 2005
Bachelor's Degree in Social Work
Professional Skills
- Excellent organizational skills, ability to manage multiple ongoing tasks and meet strict deadlines in a fast-paced environment
- Demonstrate effective listening, time management, organizational and interpersonal skills
- PC skills – demonstrate proficiency in software applications as required
- Clinical experience in medical/surgical acute care settings; Sub-acute/Skilled/Rehabilitation care experience desirable
- Excellent communication verbal, written and interpersonal communication skills required
- Exhibits responsibility for professional development and maintaining required clinical knowledge, technical skills, training and credentials
- Proven ability to manage multiple, time-sensitive priorities and adherence to all deadlines, while remaining organized
How to write Clinical Reviewer Resume
Clinical Reviewer role is responsible for database, training, software, excel, auditing, compensation, coding, reporting, research, insurance.
To write great resume for clinical reviewer job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Clinical Reviewer Resume
The section contact information is important in your clinical reviewer resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Clinical Reviewer Resume
The section work experience is an essential part of your clinical reviewer resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous clinical reviewer responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular clinical reviewer position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Clinical Reviewer resume experience can include:
- Excellent communication skills; able to discuss sensitive/ confidential information in a professional, unbiased manner
- Proven customer service skills; work with providers and members to ensure satisfaction of interaction despite unexpected/ undesired outcomes
- One year nursing experience required
- Work experience with at least 3 recent years providing direct service or case management
- The job requires at least two (2) years of experience working with individuals with a mental health diagnosis
- Insurance verification experience, preferably in a inpatient/outpatient surgical setting
Education on a Clinical Reviewer Resume
Make sure to make education a priority on your clinical reviewer resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your clinical reviewer experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Clinical Reviewer Resume
When listing skills on your clinical reviewer resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical clinical reviewer skills:
- Communicate effectively with physician offices on incomplete orders
- Demonstrated ability in researching and assisting clinical team in rendering coverage determinations in accordance with member contract and policy
- Experience auditing claims or medical coding
- Experience in understanding and applying Centers for Medicare and Medicaid Policies and Regulations
- Experience working with computers and PC applications and ability to learn new applications
- Experience in provider profiling and data analysis
List of Typical Experience For a Clinical Reviewer Resume
1
Experience For Senior Appeals Clinical Reviewer Resume
- Facilitate day-to-day technical functions of unit including effective delegation of work assignments
- Establish and maintain positive relationships and effective communication with internal and external customers
- Justifying treatments and documenting all communication
- Working off of a queue, 25-30 quota per day
- Support team through ongoing monitoring and delegating of unit tasks and responsibilities
- Improve operating efficiencies while maximizing provider, member and associate satisfaction
- Basic to intermediate computer proficiency and working understanding of common computer software such as Microsoft Word, Excel and Outlook
- Provides ongoing to TAR related to company’s Clinical Review process
2
Experience For Senior Recovery Resolution Analyst M&R Appeal Clinical Reviewer Resume
- Adherence to program, departmental and organizational performance metrics including
- Outbound calls to insurance companies determining why requests were denied
- Performs clinical intake and reviews cases according to the policies and procedures of company
- Maintains written documentation according to company’s documentation policy
- Reviews daily schedule and prepares summary of information, including amounts to be collected from patients
- Works patient facing holds to resolve and get claims out the door
- Act as primary point of contact for associates in resolving inquiries
- Coach and counsel associates offering guidance on workflows, complex issues and recent communication/action steps
3
Experience For Physician Clinical Reviewer Resume
- Contribute to performance planning and associate Performance reviews
- Foster a team-based environment by participating in various activities that lead to associate support and member and provider satisfaction
- Integrate as part of working team and function independently to complete assigned workload
- Achieve a passing score on the yearly InterQual interrater reliability test
- Documents all communication with medical office staff and/or MD provider
- On a requested basis, reviews appeal cases and/or attends hearings for discussion of utilization management decisions
4
Experience For Initial Clinical Reviewer Resume
- Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process so as to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as URAC and NCQA guidelines
- Assists the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support
- Pre-certifications, prior authorizations, and referrals for chemotherapy treatments, injections, and radiation treatments
- Participates in data compilation for audits and initial and reaccreditation site visits
- Periodically attends voluntary in-person professional development seminars offered at various annual meetings (for example, ASMBS , ACS NSQIP, and the ACS Clinical Congress)
- Serves as an educational resource on the MBSAQIP Data Registry Platform for internal and external audiences by developing educational material and delivering presentations
- Responsible for completing phone screening follow-up for admissions and continued placement in Medicaid certified nursing facilities, utilizing federal and State’s criteria
- Reviews and communicates information with providers, utilizing computer database system for determining on-site assessment completion
- Performs clinical intake and reviews cases according to the policies and procedures
5
Experience For Clinical Quality Liaison Clinical Reviewer Resume
- Maintains written documentation according to company's documentation policy
- Use of clinical tools and information / data to conduct comprehensive assessment of member eligibility and health needs
- Evaluation of member's clinical status, benefit plan, and appropriateness for internal and external programs and sites of service in order to facilitate determination of cost-effective, medically necessary plan of care
- Use of negotiation skills to secure appropriate services to meet identified healthcare needs
- Interaction with treatment providers, PCPs, physicians, and facilities as needed to support the plan of care
- Regular interactions with supervisors, managers, and physicians to discuss level of care questions, concerns, discharge needs, and barriers to achieving the most cost-effective, medically appropriate plan of care
- Presentation of cases at rounds and follow-up with physicians as necessary to obtain physician input and achieve optimal outcomes
- Monitor clinical quality concerns and refer appropriately
- Identify and escalate quality of care issues through established channels
6
Experience For QM Clinical Reviewer Resume
- Monitor clinical care services provided to a caseload of members to optimize clinical outcomes of a given episode
- Manage caseload to optimize attainment of goals around HEDIS measures, CMS Stars, and other outcomes, quality, and accreditation metrics
- Ensures proper assignment of ICD-10 codes to identified conditions
- Engages and educates members of the Quality Management Medical Reviewer team, other areas of the company and external stakeholders
- Performs an initial evaluation of the referrals appropriateness for CareCentrix services, researches/identifies all potential payer sources and determines the primary payer. Documents demographic/clinical/payer information and determines coverage availability for requested services and passes information on in a timely manner.
- Educates patients on insurance coverage and benefits including deductible, out-of-pocket expenses
- Prepares cost estimation for all treatments and meets with all patients to discuss financial requirements
- Assesses patient financial need, sets up payment arrangements and identifies appropriate financial assistance
- Meets with all new patients to complete practice registration
7
Experience For Quality Clinical Reviewer Resume
- Verifies patient insurance and documents benefits in appropriate system
- Obtains referrals and authorizations for treatment
- Enters and maintains accurate patient demographics
- Works assigned patient balance ATB and collections
- Familiarity with the principles and procedures of utilization management as practiced in managed care organizations, experience with cost benefit analysis, quality assurance and the continuous quality improvement process is desirable
- Current, unrestricted license to practice medicine in one or more states of the United States
- A licensed Physician practicing as one of the following: Anesthesiologist, Cardiologist, Emergency Medicine, Gastroenterologist, Neurologist, Oncologist, Orthopedic Surgeon, Otolaryngologist, Pain Management, Radiologist or Urologist
- Optimize levels of service to internal and external customers to enhance overall member and provider satisfaction
8
Experience For DRG Clinical Reviewer Resume
- Communicate key information to leadership on day-to-day team activities and suggest process improvements
- Make decisions, in consultation with Business Leader, to ensure timely resolution of provider issues and problems
- Disseminate benefit and program changes and information in organized and timely fashion
- Assist in implementation of and adherence to corporate, division and team policies and procedures
- Perform quality reviews, on a regularly scheduled basis, of cases and recorded calls, where applicable
- Meet or exceed annual performance goal of 90% cumulatively for case audits and recorded call audits, where applicable
- Coach and mentor associates to improve the quality and accuracy of case management plan of care
9
Experience For Bariatric Clinical Reviewer Resume
- Maintain an active case load
- Thorough knowledge of MCPS
- Current, unrestricted license to practice medicine or chiropractic in one or more states of the United States
- Licensed Master's level social worker or independent Licensed Behavioral Health professional
- Experience in working with total quality improvement or behavioral healthcare background in treatment modalities, psychopharmacology, federal/state regulatory guidelines, performance measurement
- Clinical experience required
10
Experience For Nsqip Surgical Clinical Reviewer Resume
- Experience with managed behavioral health and accreditation processes
- Managed behavioral health and accreditation processes
- Quickly develop an alliance with providers via telephone
- Healthcare quality improvement
- Acts as a mentor and provides guidance to fellow staff members related to complaint handling. Mentors staff members regarding complaint processing. Acts as a go to resource for department staff members on complex complaints
List of Typical Skills For a Clinical Reviewer Resume
1
Skills For Senior Appeals Clinical Reviewer Resume
- Experience in both nurse review and assisting with
- Current state license or registration in good standing
- Experience in personal computer applications, database management, spread sheets, and word processing
- Previous utilization management experience in a managed care and/or hospital setting Computer proficiency
- Demonstrated ability to handle escalated calls and to clearly and articulately deliver messages regarding decisions
- Possess initiative and solid, logical thinking capabilities
- Serves as an educational resource on the STS for internal and external audiences by developing educational material and delivering presentations
2
Skills For Senior Recovery Resolution Analyst M&R Appeal Clinical Reviewer Resume
- Knowledge of ICD-10 Coding
- Attends Morbidity & Mortality conferences and MBSAQIP training calls to ensure reliable data collection of postoperative occurrences
- Knowledge of home health coding
- Parse and Index incoming orders to appropriate destination
- Conduct on-site reviews of Member’s abilities to assist with determining medical necessity for assigned program and health care services
- Maintain positive working relationships with applicant/participants, and relevant informal supports, provider organizations, and state agencies
- Expertise in one or more of the following specialty areas: acute medicine, long term care, mental health, disabilities or equivalent
- Case Management and Clinical Review background
- Identifies 100 percent of bariatric surgery patients for inclusion in the data registry
3
Skills For Physician Clinical Reviewer Resume
- Responsible for the accurate and timely entry of data into the program’s database
- Responsible for the accurate and timely entry of data into the program's database and meets the caseload accrual requirement protocol
- Establishes effective working relationships with members of the hospital community, especially staff in the Specialty Clinics, Medicine, Nursing, Medical Records, and Information Systems Departments whose support is necessary for the management and success of the Program
- Certified Coder (CPC / CCS) and / or current LPN / RN Licensure
- Clinical practice, prior chart review, clinical coding experience; or any combination of education and experience, which would provide an equivalent background
- Experience in acute care environment
4
Skills For Initial Clinical Reviewer Resume
- Experience in acute care environment
- Previous utilization management experience in a managed care
- Strong clinical background in orthopedics, neurology and rehabilitation
- Utilization review or quality assurance experience
- Documented experience as team or project leader
- Experience in medical literature search and analysis
5
Skills For Clinical Quality Liaison Clinical Reviewer Resume
- Experience in managed care or in workers’ compensation insurance
- Healthcare quality improvement experience
- Comprehensive knowledge and experience with managed care benefit plans
- Local travel required within assigned territory (mileage, tolls reimbursed)
- Current, active California RN license
- In medical case management
- Registered clinician with an active professional Massachusetts license
6
Skills For QM Clinical Reviewer Resume
- Work a flexible schedule required
- Lift 30 pounds, move intermittently throughout the work day, inclusive of sitting, standing and bending, pushing, pulling, or moving objects and clients
- Knowledge of home health coding (ICD-10)
- Current State of Louisiana Registered Nurse License
- NSQIP certification or willingness to obtain NSQIP certification upon hire
- In a managed care health care environment, including 2 years’ experience in Medicare managed care. Familiarity with applicable state regulations and NCQA standards required
- In radiology scheduling for a hospital
7
Skills For Quality Clinical Reviewer Resume
- Review Orders for appropriateness and completeness
- Ensure accurate and necessary data sets are present all orders
- Build relationships with physician offices to further than advancement of the department objectives
- Complete order review in an extremely tight turnaround time
- Health care professional with active Massachusetts license
- Proficiency in Microsoft Office: Excel, Word,; Internet
- Assess treatment needs and make recommendations that impact desired outcomes and quality of care
- New York State LPN, RN, LCSW, LMSW License or Foreign Medical Graduate required
8
Skills For DRG Clinical Reviewer Resume
- Interface with various external customers, including but not limited to, delegates, and accreditation, federal, and state agencies. This involves explaining ConnectiCare’s policies and processes as they relate to the external entity, negotiating the resolution of issues, developing workflows, and implementing quality improvements
- Responsible for assuring the highest possible data quality through accurate, complete, and timely data entry and abstraction for the ACS MBSAQIP database for 100 percent of bariatric procedures for both Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital
- Complete pre-admission and concurrent reviews for admissions and continued placement in Medicaid certified nursing facilities, utilizing federal and State’s criteria
- Receives/responds to incoming calls from referral sources/potential clients, exchanges information to identify the clients’ needs and determines CareCentrix' ability to meet them
- Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct
- Conduct pre-certification, concurrent, and retrospective reviews for applicable product lines and levels of care, with emphasis on utilization management, discharge planning, coordination of services, clinical outcomes, and quality of services
- Stays abreast to changes in Fidelis’ Performance Management measures and systems and changes in clinical guidelines
- Perform reviews of medical records and standards; post completed review reports with the number of records reviewed and quality issues noted
9
Skills For Bariatric Clinical Reviewer Resume
- Collaborate with providers and adhere to clinical standards of care to ensure appropriate outcomes; practice and adhere to departmental, state and national guidelines
- Communicate in an efficient, effective, and friendly manner with providers, internal, and external staff
- Educate providers on clinical guidelines and QARR/HEDIS measures
- Attend educational workshops; review professional publications; establish personal networks; participate in professional societies to maintain professional and technical knowledge
- NYS RN License, NYS LPN license or Foreign Medical Graduate required
- Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of applicants/participants requiring health care services, to include outpatient and home based therapy services
- Conduct on-site visits in order to assess and re-assess the Member’s abilities and medically necessary healthcare needs and services
- Determine and authorize services for applicants/participants in accordance with program guidelines and regulations
- Conduct routine and ad-hoc evaluations and re-evaluations of applicants/participants services
10
Skills For Nsqip Surgical Clinical Reviewer Resume
- Contact providers, state agency offices, and clients to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination
- Travel statewide to applicant/participant homes and service providers places of business
- Identifies 100 percent of bariatric surgery patients for inclusion in the MBSAQIP data registry. Collects preoperative, intra-operative, 30-day postoperative, and long-term (six month and annual thereafter) follow-up data components for the program through the effective utilization of the hospital
- Medical record systems and through a coordinated effort with individual surgeon office staff
- Collects preoperative, intraoperative, 30-day postoperative, and long-term (six month and annual thereafter) follow-up data components for the program through the effective utilization of the hospital medical record systems and through a coordinated effort with individual surgeon office staff
- Establishes effective working relationships with members of the hospital community , especially staff in the surgery, medicine, nursing, medical records, and information systems departments and individual bariatric surgeons’ offices whose support is necessary for the management and success of the program
List of Typical Responsibilities For a Clinical Reviewer Resume
1
Responsibilities For Senior Appeals Clinical Reviewer Resume
- Applies knowledge of global device regulatory requirements in order to support Post Market MDR/Vigilance reporting decision process within regulatory timeframes
- Abides by and demonstrates the company Mission –Vision –Values through both behavior and job performance on a day-to-day basis
- Interfaces with Quality Engineering and other departments for product investigations and trend reporting
- Responsible for the reviewing of MDR/Vigilance decision trees and is able to review and complete MDR/Vigilance submissions
- Assist in the timely closure of assigned complaint files in a consistent and timely manner, and ensures that all pertinent information is contained within the file prior to closure. Monitors and reports on complaint metrics as required
- Responsible for receiving, reviewing, entering, and evaluating data into the Compliant Management Database regarding customer/patient product inquiries and complaints and further processing complaint files, as necessary
2
Responsibilities For Senior Recovery Resolution Analyst M&R Appeal Clinical Reviewer Resume
- A licensed Physician practicing as Cardiologist
- Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge
- Assist with request to customers and provides preliminary support as required. Refers complex inquiries to direct supervisor, as needed
- Active Registered Nurse license required
- Board Certified by one of the following: American Board of Medical Specialties (ABMS), American Board of Cardiovascular Medicine (ABCMC), Internal Medicine (ABIM/ABOIM)
- Uses clinical expertise, reviews utilization information concerning patient care and matches those needs to available care options, within the CareCentrix guidelines and specific plan payer criteria
3
Responsibilities For Physician Clinical Reviewer Resume
- Verifies completed case verifications funneled through Triage, verifying information, applying business rules and determining the next steps
- Records the outcome of all inquiries and referral calls received, and makes follow-up calls when an inquiry or referral cannot be serviced
- Tracks/reports on inquiries/referrals and identifies alternative resources when CareCentrix solutions are not available
- Master's level clinician
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