Clinical Review Specialist

1 week ago


Harlingen, Texas, United States Prime Healthcare Full time

Position Overview

Become a vital part of a dedicated team at Prime Healthcare, where we uphold the highest standards of quality, compassion, and community engagement. Our facility is recognized for its comprehensive medical services, including Cardiovascular Care, Emergency Services, Neuroscience, Orthopedic Care, Radiology, Rehabilitation, and Surgical Services, serving the community with excellence for over 15 years.

We are committed to fostering a diverse and inclusive workplace, adhering to a strict non-discrimination policy that ensures equal opportunities for all employees.

Key Responsibilities

- Conduct thorough clinical evaluations of patient medical records in partnership with the Chief Medical Officer (CMO)
- Actively participate in Case Management and Utilization Review (UR) meetings
- Provide ongoing education to various departments
- Review patient charts to confirm compliance with clinical admission and treatment standards
- Manage records requests from payers and fiscal intermediaries
- Deliver updates on the status of open and closed accounts for Utilization Review and Case Management reporting
- Make independent decisions based on sound clinical judgment
- Stay updated on federal, state, and intermediary regulations regarding different levels of care
- Facilitate discharge referrals as requested by clinical staff, fiscal intermediaries, patients, and families
- Perform additional assigned responsibilities as needed

Qualifications

Education and Experience Requirements

Required:

  • Master of Public Health (MPH) or a relevant post-graduate degree in healthcare
  • Medical or Dental Graduate
  • Knowledge of Clinical Pathophysiology and Pharmacology

Preferred:

  • ECFMG Certification or a Bachelor's degree from a US-accredited institution in Health and Human Services
  • Experience in Utilization Review or Case Management
  • A minimum of 1 year of clinical experience in acute care environments
  • Strong written and verbal communication skills
  • Exceptional critical thinking and interpersonal skills
  • Able to work independently in a fast-paced setting
  • Proficient in computer data entry, with a typing speed of at least 35 wpm


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