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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.

Clinical Risk Specialist

Healthcare Analytics/Payment Integrity
Irvine, CA
Full Time
Senior Level Career (10+ yrs experience)
$90,000 - $140,000

Published on 03/28/2023

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