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Clinical Review Specialist

3 months ago

Charleston, United States Trident Medical Center Full time

**Schedule: Monday-Friday Day Shift**:
Introduction

Do you have the career opportunities as a Clinical Review Specialist you want with your current employer? We have an exciting opportunity for you to join Work from Home which is part of the nation's leading provider of healthcare services, HCA Healthcare.

**Benefits**:
Work from Home, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

- Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
- Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
- Free counseling services and resources for emotional, physical and financial wellbeing
- 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
- Employee Stock Purchase Plan with 10% off HCA Healthcare stock
- Family support through fertility and family building benefits with Progyny and adoption assistance.
- Referral services for child, elder and pet care, home and auto repair, event planning and more
- Consumer discounts through Abenity and Consumer Discounts
- Retirement readiness, rollover assistance services and preferred banking partnerships
- Education assistance (tuition, student loan, certification support, dependent scholarships)
- Colleague recognition program
- Time Away From Work Program (paid time off, paid family leave, long
- and short-term disability coverage and leaves of absence)
- Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Learn more about Employee Benefits

**_ Note: Eligibility for benefits may vary by location._**

Our teams are a committed, caring group of colleagues. Do you want to work as a(an) Clinical Review Specialist where your passion for creating positive patient interactions is valued? If you are dedicated to caring for the well-being of others, this could be your next opportunity. We want your knowledge and expertise

**Job Summary and Qualifications**:
The Clinical Review Specialist is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements.

In this role you will:

- Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services.
- Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids
- Submit authorization request based on state deadlines using various State portals
- Review deferred accounts and update according to payer request
- Review denied account to determine justification for Appeal requests
- Maintains clinical documentation according to HCA’S documentation policy
- Meet productivity requirement as established by leadership
- Assists in the orientation and training of new clinical staff
- Attend training as required
- Perform other duties as assigned

Qualifications:

- High school diploma or GED required
- Successful completion of an accredited Licensed Practical/Vocational Nurse Program
- A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting
- A minimum of one-year experience with denials and appeals in a clinical setting preferred
- A minimum of one-year experience in a patient care setting
- Experience working in a remote setting
- Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload.
- Currently licensed in applicable state
- Maintains an active LPN/LVN license in good standing

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**Parallon** provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities.

HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 b