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Medical Records Review Consultant
2 months ago
Role Summary
The Clinical Review Specialist plays a crucial role in the meticulous evaluation and interpretation of medical documentation and claims to facilitate the appeal process for denied insurance claims. This position involves composing appeal letters grounded in clinical expertise and understanding. The role is primarily remote, with the flexibility to work in an office setting if preferred. Occasionally, the Clinical Review Specialist may be requested to conduct in-person training sessions or seminars for staff with prior notice.
Work Schedule
This is a part-time role with the possibility of transitioning to full-time. Initially, the position requires a commitment of 15 hours per week, with the potential for increased hours based on the workload and the candidate's availability.
Key Responsibilities
This list is not exhaustive; additional duties may be assigned. The candidate should be familiar with various types of hospital documentation, including but not limited to medical records, UB-04 forms, Explanation of Benefits (EOBs), itemized billing statements, hospital account notes, appeal letters, and denial/approval notifications.
- Utilize TimeMatters for work assignments and to communicate claim notes clearly and concisely.
- Analyze and interpret medical records and claims documentation (such as EOBs and UB-04s) to support appeals for denied insurance claims related to both inpatient and outpatient services.
- Employ clinical judgment and knowledge to assess medical necessity, admissions, and other clinical evaluations.
- Draft, review, and refine appeal letters, including those prepared by other team members.
- Ensure adherence to the correct letter format, guidelines, and logical arguments.
- Verify that letters are coherent and easily understandable.
- Confirm that all necessary attachments are included with the appeal.
- Ensure page number citations correspond accurately with the medical records.
- Handle high-value and/or urgent cases promptly.
- Submit all appeals, follow-ups, and documentation within the required filing periods.
- Comply with all HIPAA regulations and other compliance standards.
- Assist in developing clinical training materials for staff.
- Participate in the clinical training of other team members.
Qualifications Required
A Bachelor’s degree from an accredited four-year institution is required. The Clinical Review Specialist should hold a valid license as a Registered Nurse (including RN, APRN, CRNP), Nurse Practitioner (including CNP, LNP, NPC), Physician Assistant, Physician, or another qualified healthcare professional. Current active licensure is not mandatory.
Compensation Package
- Hourly rate starting at $45, commensurate with qualifications.
- Eligibility for monthly performance bonuses after a designated period of employment.
- Potential for additional benefits, including 401k, health insurance, disability insurance, and commuter benefits, if transitioned to full-time status.
