CLINICAL REVIEWER SKILLS, EXPERIENCE, AND JOB REQUIREMENTS

Updated: Nov 26, 2024 - The Clinical Reviewer meticulously evaluates medical records and performance data within a hospital setting, ensuring adherence to nursing principles and state and federal regulations. With expertise in data analysis and performance improvement, this role focuses on identifying trends and making recommendations that enhance patient care. Essential to the position is the capacity to communicate effectively with Medical Review Board physicians and other healthcare professionals, supporting ongoing collaboration and service excellence in the Retirement Systems Division.

Essential Hard and Soft Skills for a Standout Clinical Reviewer Resume
  • Medical Knowledge
  • Data Analysis
  • Regulatory Knowledge
  • Documentation Skills
  • Research Proficiency
  • Quality Assurance
  • Drug Knowledge
  • Statistical Proficiency
  • EHR Proficiency
  • Coding/Billing Skills
  • Detail-Oriented
  • Effective Communication
  • Critical Thinking
  • Problem Solving
  • Quick Adaptability
  • Interpersonal Skills
  • Time Management
  • Team Collaboration
  • Empathetic Approach
  • Decisive Judgment

Summary of Clinical Reviewer Knowledge and Qualifications on Resume

1. BS in Nursing with 4 years of Experience

  • Good GCSE standard of education or equivalent
  • Degree in the health-related subject is desirable
  • Social Care / Management Qualifications is desirable
  • Excellent written, oral, presentation, and communication skills
  • Ability to facilitate improvement and influence at all levels
  • Ability to establish positive working relationships with a wide range of internal and external stakeholders
  • Good judgment and analytical skills
  • Current knowledge of CQC and CI regulations, frameworks, and inspection process
  • Knowledge of the care sector including regulatory and contractual frameworks and relevant legislation
  • Knowledge and understanding of the needs of people we support
  • Experience in carrying out regulated activity audits or inspections
  • Knowledge of Human Rights and Equality legislation
  • Excellent breadth and depth of knowledge of personalization and inclusion agendas
  • Highly self-motivated, proactive, and positive
  • Ability to work on own initiative and to established deadlines
  • A flexible and innovative approach to work

2. BS in Medicine with 6 years of Experience

  • Nursing experience along with some analytics experience.
  • Registered Nurse Licensure from Kansas State board of Nursing required upon hire.
  • Certification in Healthcare Quality.
  • Nursing experience in hospital environment.
  • Experience in data collection and performance improvement.
  • Basic knowledge of nursing principles and techniques for medical, surgical, and mental health practices.
  • Working knowledge of principles and practices of state and federal laws standards, certifying and accrediting bodies, guidelines, and regulations applicable to the area of assignment.
  • Ability to identify trends, process improvements, recommendations, and statistics.
  • Demonstrated ability to gather, compile and perform preliminary analysis on medical records.
  • Proven ability to work in partnership with Medical Review Board physicians, disability analysts, supervisors, and the section chief providing service to the members of the Retirement Systems Division.
  • Demonstrated ability to effectively communicate information to Medical Review Board physicians, disability analysts, supervisors, and the section chief on a daily basis in a concise and descriptive manner verbally and in written form.
  • Intermediate ability to utilize MS Office to include Word and Outlook are needed

3. BS in Public Health with 5 years of Experience

  • Experience in coding, medical record documentation, responding to payer charge or forensic audits.
  • Working knowledge of CPT/HCPCS Coding, billing requirements and familiarity with billing and claim forms
  • State and Federal regulations concerning the use, disclosure, and confidentiality of patient records
  • Effective chart review skills and proficiency in targeting relevant clinical data within the medical record.
  • Familiarity with medical auditing principles
  • Excellent oral and written communication skills.
  • Effective negotiating skills including the ability to resolve cited charge issues by extracting supportive documentation for dispute resolution/appeals purposes is required.
  • Ability to review and interpret clinical data to determine whether the services are well supported in the documentation.
  • Ability to interact with all levels of health care personnel and hospital/finance management and build strong working relationships with internal and external customers.
  • Strong organizational and time management skills.
  • Ability to work independently in a role that requires flexibility in an environment that is deadline driven.
  • Ability to research applicable CMS regulations, charging policies and payer clinical and reimbursement policies
  • Experience with computer software programs such as Word and Excel are required.
  • Ability to function as a department subject matter expert and resource with a focus on contributing to the achievement of departmental and corporate goals.
  • Strong knowledge of acute hospital utilization review and case management is a plus
Relevant Information
Clinical Manager Skills, Experience, and Job Requirements
Clinical Psychologist Skills, Experience, and Job Requirements
Clinical Specialist Skills, Experience, and Job Requirements
Clinical Researcher Skills, Experience, and Job Requirements