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Clinical Review Specialist

2 months ago

Franklin, Tennessee, United States XSOLIS, Inc. Full time
About the Role

Xsolis, Inc. is seeking a highly skilled Clinical Review Specialist to join our team. As an Appeals Nurse Coordinator, you will play a critical role in providing concurrent review and appeal support services for our growing client base.

Key Responsibilities
  • Provide clinical reviews in accordance with Managed Care and CMS Regulatory Requirements
  • Assist with assigning appropriate level of care on a case-by-case basis
  • Determine if ICD-10 codes/DRG appropriately documented and meet clinical documentation integrity guidelines
  • Assist with the denial management process and construction of appeal correspondence
  • Determine if professionally recognized standards of quality care are met
  • Provide feedback to internal and external partners regarding level of care, length of stay, rationale on outcomes of cases, and clinical documentation for ICD-10s
  • Apply clinical and industry guidelines, and use of in-depth knowledge that supports medically necessity of services rendered, and clinical documentation integrity of ICD-10s
  • Identify opportunity to request additional, more complete, medical record documentation
  • Review cases with screening criteria, such as InterQual, MCG or other appropriate platforms
  • Continually keep abreast of technology changes, regulatory issues, and medical practice through ongoing training and self-directed research
  • Provide client with a detailed Summary of Cases to track any discovery of trends or other pertinent information
  • Research/Review contracts and speak to the payer on behalf of the client on why a claim decision was made
Requirements
  • Active RN or LPN license
  • 3-5 years of clinical practice, with at least 2 of these years in auditing, appeals, medical review, and CDI
  • Case management or Utilization Review experience and CM, coding and/or CDI certification a plus
  • Experience working with multiple instances of Electronic Medical Records (i.e. Meditech, Cerner, EPIC)
  • Knowledge of the query process and utilization of CDI guidelines (Pinson & Tang, ACDIS, etc.)
  • Experience using case management guidelines (InterQual, Milliman, CMS 2MN Rule)
  • Excellent communication skills
  • CPT, ICD-10, and DRG coding
  • MS Office Suite - Specifically Word and Excel
  • Organization and prioritization
  • Medical record technology
  • Adobe DC/PDF
About Xsolis, Inc.

Xsolis, Inc. is an AI-driven technology company with a human-centered approach, fostering collaboration between healthcare providers and payers through real-time transparency, objective data for increased accuracy and alignment of medical necessity decisions, and more efficient outcomes.