Clinical Review Clinician


Metairie, LA

Industry: Misc. Healthcare


Less than 5 years

Posted 369 days ago

  by    Benjamin Workman

Margin Recovery International, LLC. - Metairie, LA

This individual will be responsible for one or more types of medical record medical necessity clinical reviews. Clinical reviews may be (1) inpatient or outpatient, (2) for any payer type and (3) may be concurrent, pre-bill or retrospective based on the client service provided. Examples work activities include and are not limited to: Clinical Pre-certifications, Utilization Reviews, Clinical Appeals, and Patient Status Reviews. This role requires strong communication skills both verbal and written as well as expertise in applying medical necessity criteria, doing research on current clinical practices and rules/regulations, and data analyses for the purpose of identifying for the client areas of performance improvement opportunity. The Clinical Review Clinician will be working directly with clients; managing their accounts and relationships effectively.

Essential Duties and Responsibilities

Include the following:

  • Reviews all available encounter documentation, including but not limited to, medical record and payer correspondence
  • Utilizes InterQual® (or other client criteria set) to apply medical necessity criteria and determine appropriate patient status and level of care medical necessity
  • Utilizes applicable payer guidelines to obtain patient pre-certification/authorization and understand covered benefits; For government payers utilizes local and national coverage determinations (LCD, NCD) and other as applicable
  • Authors factual appeal letter based on available documentation and/or pertinent research articles to support clinical appeal
  • Documents clinical rationale for pre-certification, status determination, or appeal outcome in client system
  • Complies with applicable government regulations as pertains to Utilization Review and related billing
  • Keeps MRI leader(s) informed of outcomes; progress, opportunities, and trends
  • Meets or exceeds deadlines
  • Creates &/or contributes to Client reporting
  • Provides effective Client communication – calls, e-mails
  • All other responsibilites as assigned


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Expertise with medical necessity criteria set(s)
  • Knowledge/ ability to conduct through on-line research of accepted standards of practice, provider manuals, regulations, etc.
  • Understanding of hospital billing and reimbursement; basic patient accounting principles including but not limited to: adjustments, credits, debits, patient liability and revenue codes
  • Ability to gain knowledge of client’s general hospital policies and procedures, departments, and revenue cycle technology
  • Establishes strong working relationships between financial and clinical department leaders
  • Communicating with partners such as physician offices to secure necessary documentation to support pre-certification or appeal
  • Customer service orientated and understanding of key drivers of client satisfaction; ability to bring improvements to the overall customer experience
  • Demonstrates professionalism in all interactions withinternal and external clients, including written, client-facing, and over the phone
  • Strategic thinking skills
  • Knowledge of Microsoft Office tools including Excel, Outlook, SharePoint, PowerPoint and Word
  • Basic proficiency in computer skills including but not limited to typing, spell check and use of standard office equipment such as copier, fax
  • Prioritize and manage multiple tasks/assignments and meet established timeframes
  • Strong presentation and communication skills
  • must have strong verbal and written communication skills
  • ability to interact with numerous client hospital departments to obtain appropriate info needed to appeal/resolve claims
  • ability to interact with payer representatives to bring account to resolution
  • ability to communicate to a wide range of audiences from senior executives to front-line employees
  • Ability to work independently and as a team member
  • Ability to work with little to nosupervision in either office setting or in a remote setting
  • Maintains professional licensure through continuing education


Include minimum education, technical training, and/or experience required to perform the job.

  • Valid nursing license
  • Minimum of 1year clinical experience in an acute care setting and
  • Minimum of 1yearwith2 - 5years preferred of health care revenue experience cycle (e.g. Clinical Pre-cert, Utilization Review, Clinical Appeals)
  • Previous hospital and/or insurance utilization/ case management experiencepreferred
  • Strong fundamental knowledge of third party practices, including Managed Care, Medicare, Medicaid preferred
  • Understanding of Government audits related to medical necessity preferred
  • Understanding of explanations of benefits (EOB), Managed Care contracts, Contract language and Federal and State guidelines preferred
  • Experiencewith various health care patient accounting and reconciliation systems and electronic medical record systems preferred
  • Understanding of ICD-9 and ICD 10, CPT/HCPCS coding and medical terminology though Coding or Clinical Documentation Specialist experiencepreferred
  • Previous utilization of medical necessity criteria sets (InterQual®, MCG, NCD’s, LCD’s) preferred
  • Intermediate skills in setting up, maintaining and working with Excel spreadsheets and graphs and PowerPoint reports preferred

The above statements describe the general nature and level of work being performed as of the date of preparation and approval. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of the position. Employees holding this position will be required to perform any other job-related duties as requested by management. The job description does not constitute an employment agreement between the employer and employee, and all requirements are subject to possible modification to reasonably accommodate individuals with disabilities.


The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Must be able to work in sitting position, use computer and answer telephone for long periods of time
  • Ability to lift and/or move up to 25 pounds
  • Specific vision abilities required by this job include close vision.

Job Type: Full-time

Salary: $55,000.00 to $70,000.00 /year


  • Associate


  • Utilization Review: 1year
  • Clinical Appeals: 1year
  • Utilization Management: 1year

Required licenses or certifications:

  • LVN
  • RN

$55K - $70K