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Clinical Care Reviewer

(Remote), Oklahoma
Company:  KFMC Health Improvement Partners
Job Title:  Nurse Clinical Care Reviewer
Job Classification:  Exempt, Full-time
Risk Designation:  Moderate
Work Schedule:   Mutually determined
Reporting Relationship:  Director of Clinical Care Review & Quality Improvement
Work Location:   Remote, with residency in Oklahoma 

Primary Accountability:
This position is responsible for completing reviews and processing of selected cases and/or special requests in a timely and accurate manner and in accordance to KFMC contract requirements. This position works in collaboration with internal staff members and/or departments as well as external sources; the position is expected to function independently, as well as collaboratively.
Major Duties:
  • Completion of review functions based on established procedures and contract requirements.
  • Communicates with Medical Director, Physician and Peer Reviewer, as necessary.
  • Provide education to clients and providers related to review activities as needed.
  • Participation in Internal Quality Control activities.
  • Serve as a resource person for external inquiries received from hospital personnel, patients, physicians, federal and state government officials, and private clients related to job assignments.
  • Report to the Director of Clinical Care Review & QI all information, questions or complaints from outside customers that cannot be resolved.
  • Assist in the development, revision and implementation of KFMC programs, policies and procedures.
  • Keep team members informed of all activities within area of responsibility.
  • Participate in case review improvement where customer satisfaction and efficiency can be improved.
  • Keep current on contract requirements, latest version of ICD coding requirements, and review procedures. Must be able to adapt to change easily and apply the information learned to his/her job as a Clinical Care Reviewer.
  • Assist the Director with developing and updating procedures as necessary.
  • Assists with resolution of project delays.
  • Responsible for project scheduling, attending all project meetings, and project completion documentation.
  • Assist in project execution to ensure deadlines, scope, and budget costs are met.
  • Keep informed of industry changes, trends, and best practices and assess the potential impact of those changes on company practices.
  • Assist in ensuring the company’s compliance with regulatory requirements, policies are in place, and that procedures are documented, implemented, and communicated to all individuals impacted.
  • Graduate of an accredited college or university. Completion of an RHIT/RHIA, Nursing degree, or Certified Coding Specialist (CCS) is preferred.
  • A minimum of two (2) years of experience in a project managerial, clinical coding, or clinical position in the health care field is required. 
  • Knowledge of medical terminology.
  • Ability to read handwritten medical records.
  • Intermediate to advanced computer skills is required.
  • Strong and effective written and verbal communication skills.
  • Interpersonal skills to collaborate effectively with internal and external customers.
  • Strong attention to accuracy and detail required.
  • Ability to identify and initiate process improvements.
  • Ability to communicate effectively and express comments and opinions clearly and concisely in a diplomatic manner.
  • Strong organizational skills and the ability to coordinate multiple projects.
  • Professional attitude and the ability to maintain confidentiality.
  • Demonstrated ability to work independently and as a team member.
  • Familiarity with the health care delivery system and experience in working with health care providers and/or the public.
  • Must have the ability to appraise any situation and exercise good judgment. 
  • Ability to work independently and make decisions based on contract policies and procedures.
  • Ability to demonstrate proficiency in planning, organizing, and problem-solving techniques. 
  • Must be able to interact with KFMC staff, physicians, hospital personnel, a variety of professionals, and the public in a tactful, diplomatic manner to establish rapport and win confidence. 
  • Familiarity with various computer software applications (i.e., Microsoft Office).
  • Represent KFMC professionally in appearance and conduct.
  • QIO staff with specific credentials required by their position description will provide a copy of their current credential status, and subsequent renewals to the Director of Clinical Care Review and QI and Human Resources. QIO staff are required to report an adverse change in the status of a required credential within three business days of receiving notice from the credentialing authority. Staff may submit a notice of adverse change in a credential by any format, and will submit a plan to bring the credential into compliance with the requirement of their PD.
Physical Demands:
  • Ability to sit for extended periods of time.
  • Ability to read computer screens and mail.
  • Ability to unpack and move supplies up to 50 lbs.
  • Ability to drive an automobile.
  • Ability to travel as directed by position requirements.
Work Environment:
  • Professional and deadline-oriented environment in an office setting.
  • Interaction with internal and external customers
Additional Duties:
Additional duties and responsibilities may be added to this job description at any time.
The job description does not state or imply that these are the only activities to be performed by the employee(s) holding this position.  Employees are required to follow any other job-related instructions and to perform any other job-related responsibilities as requested by their supervisor.

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