Clinical Risk Specialist

Job Summary:

The Clinical Risk Specialist focuses on reviewing and analyzing medical record data by extracting pertinent information; and formulating detailed reports to support medical conclusions and payment integrity recommendations.  The Clinical Risk Specialist works under the general direction of the Director of Clinical Services. 

Duties and Responsibilities:

• Review, analyze and interpret medical record data by extracting pertinent information.
• Analyze each claim individually to ensure adequate due diligence for our clients.
• Provide a clinical timeline that accurately documents the patient’s hospitalization by reviewing the medical records.
• Analyze and interpret hospital care charges with specific focus on room and board acuity, incidental supplies, nursing services, preventable hospital acquired conditions, pharmaceuticals, and other therapies.
• Utilize technology for hospital charge data capture.
• Formulate detailed reports to support medical conclusions and payment integrity recommendations.
• Ensure clinical audit conclusions are incorporated into the Claim Payment Integrity

Review (CPIR) report utilized for adjusted claim payments by clients.

• Collaborate with other teams to ensure final clinical audits focus on specific client requests, timeframes for audit completion, and sound clinical judgement in the case of possible appeals.
• Ensure compliance with HIPAA regulations and requirements.
• Performs other duties as assigned.

Required Skills and Abilities:

• Critical thinking with emphasis on research and analytical skills
• Creative energy with resourceful problem-solving skills
• Skillful discernment and independent judgment when reviewing complex hospitalizations
• Effective verbal and written communication skills
• Professionalism and strong work ethic
• Collaborative talent and leadership experience
• Proficient in Microsoft Office Suite or similar software.
• Ability to pass a background check.

Education and Experience:

• Current RN Licensure in state of operation.
• Advanced nursing degree is necessary.
• Recent adult acute care clinical experience,10-year minimum.
• Claim Audit experience is necessary.