HCA, Hospital Corporation of America Clinical Reviewer in Santa Ana, California
CLINICAL REVIEW SPECIALIST
Performs TAR reviews and completion of TAR requests according to Medi Cal format and deadlines
Performs Medi Cal clinical medical file review of hospital documentation for necessary clinical treatment and patient severity of illness to warrant admissions and continued acute inpatient level of care
Performs on line documentation of clinical justification for hospital stays and pre screening of files to determine if Appeal is warranted.
Documents clinical justification for Appeal requests
Conducts clinical review of cases that do not meet criteria
Performs clinical intake and reviews cases according to the policies and procedures of TOG.
Collects and enters confidential information ensuring the highest level of confidentiality in all areas.
Maintains written documentation according to TOG’S documentation policy
Provides ongoing to TAR related to TOG’s Clinical Review process Assists in the orientation and training of new clinical TAR staff in department.
Participates and understands scope of responsibility in all ongoing of the TAR Process.
Knowledge of care management plans and services in order to implement that knowledge in a clinical in-patient setting.
Knowledge of care management plans and services in order to implement that knowledge in a clinical setting.
Ability to use independent judgment related to medical record review.
Preferred RN from an accredited school of nursing
Preferred Current, active California RN license
2-3 years experience in acute care environment
3 years previous utilization management experience in a managed care and/or hospital setting
An associate or bachelor's degree in nursing or a hospital-sponsored diploma
Knowledge and proficiency of established clinical standards and guidelines with Medi-Cal
Good organizational skills preferred
Experience in both nurse review and assisting with the utilization review appeals process.
Title: Clinical Reviewer
Location: California-Santa Ana-Santa Ana (SAN) - RCPS
Requisition ID: 26576-120930