Clinical Risk Specialist
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.