Gainesville, Florida
Vancouver, British Columbia, Canada
La Jolla, California
Cincinnati, Ohio
Anderson, South Carolina
Bronx, New York
Saint Louis, Missouri
Posted: 05-Jan-23
Location: Frisco, Texas
Salary: Open
Internal Number: 2305001591
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
JOB SUMMARY
The Clinical Services Specialist is a member of a multi-disciplinary team that is responsible for reviewing patient medical records to determine medical necessity. The Clinical Specialist assesses medical necessity of patients by reviewing clinical findings in the patient�s chart as well as reviewing patient care activities, assessing that evidence-based practice and/or regulatory/payor requirements have been achieved. The Clinical Specialist when necessary will communicate the patient�s medical necessity review to the patient�s insurance provider. This position integrates functions typically considered to be case management, care coordination and/or utilization management.
Must comply with all policies & procedures that pertain to HIPAA including the minimum necessary requirements for this position. The employee has access to the entire medical record for the purpose of conducting a medical necessity review. Access to medical records should only be limited and only utilized to meet the requirements of the employee�s job description.
Must limit the protected health information (PHI) disclosed or requested to the amount reasonable necessary to achieve the purpose of the request. The disclosures or requests that occur on a routine basis include: patient demographics, condition, notification of actual/potential victim of abuse or neglect, description of injuries for the purposes of a crime investigation, actual/potential for organ donation & patient disposition updates.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
- Performing Pre-Admission, Admission, Payor Notification, Continued Stay, and/or Retro-Authorization reviews per policy and procedure.
- Responsible for promptly communicating with the team and leaders as requested regarding projects or cases assigned.
- Addressing and rectifying any client complaints as assigned.
- Staying abreast of relevant diagnostics, interventions, and pharmacological advances in medicine. As well as completing assigned education modules and trainings.
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment activity. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
KNOWLEDGE, SKILLS, ABILITIES
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.
- Conversant knowledge and experience with case management care coordination, and/or utilization review
- Comfortable researching and learning relevant evidence based care practice updates
- Demonstrated problem solving ability
- Working knowledge of and basic skills with computers
- Ability to quickly adapt to workflow updates and requirements
- Clear and concise written & verbal communication skills
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience preferred to perform the job.
- Emergency Nursing and Case Management preferred.
- Three (3) years bedside experience in the relevant clinical specialty preferred (e.g., care managers for pediatric patients should have pediatric nursing experience)
REQUIRED CERTIFICATIONS/LICENSURE
Include minimum certification required to perform the job.
- Registered Nurse license (R.N.) or Licensed Practical Nurse (L.P.N.) is required.
PHYSICAL DEMANDS
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
- Required to use fine motor skills (typing/data entry), and reach with hands and arms
- Must be able to lift up to 25 lbs
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Subject to varying and unpredictable situations, many interruptions, multiple calls, inquiries, and change
- May be required to work long hours and holidays
Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
