Clinical Review Specialist

24 hours ago


Detroit, Michigan, United States w3r Consulting Full time

Job Summary:

w3r Consulting is seeking a highly skilled Clinical Review Specialist to join our team. As a Clinical Review Specialist, you will be responsible for conducting thorough reviews of patient care services to ensure medical necessity, appropriate length of stay, and intensity of service.

Key Responsibilities:

  • Conduct prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services to ensure medical necessity and appropriate level of care.
  • Establish care plans and coordinate care through the healthcare continuum, including member outreach assessments.
  • Collaborate with healthcare providers, facilities, and members to resolve appeal requests and ensure compliance with regulatory requirements.
  • Develop and maintain knowledge of healthcare policies, procedures, and regulatory guidelines.
  • Provide education and training to healthcare professionals on clinical review processes and best practices.

Requirements:

  • Bachelor's degree in nursing, allied health, business, or related field.
  • Two to four years of clinical experience, including acute patient care, discharge planning, case management, and utilization review.
  • Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes.
  • One year of health insurance plan experience or managed care environment preferred.
  • Registered Nurse with current unrestricted license required.
  • Certification in Case Management may be preferred based on designated department assignment.

Preferred Qualifications:

  • Above average computer skills, including Microsoft Office.
  • Clinical experience in ICU, ER, or medical surgical unit preferred.
  • Utilization management experience preferred.


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