Hospital Nurses work in healthcare facilities and are responsible for providing patient care. Clinic Resume Sample 4.8. Guide the recruiter to the conclusion that you are the best candidate for the clinical review job. . Of the 300+ clients I've sent to this firm, they have boasted a 100% satisfaction rate. TheResumeClinic. The Resume Clinic is a 4.5-star rated CV Writer on Bark, serving New Orleans and surrounding areas. Strong negotiation, organizational, delegation and task prioritization skills, Strong communication skills (both verbally and in writing) and proven ability to effectively interact and maintain working relationships with operational, clinical, and financial stakeholders internal and external to the organization, Ability to work effectively in a constantly changing environment and maintain a work pace appropriate to the workload, handling multiple tasks and meeting deadlines, RN Credential - Bachelor of Science in Nursing (BSN), Knowledge and ability to conduct medical necessity validation reviews, Knowledge of DRGs and ICD-9, HCPCS and APC codes, Proficient with UCSD Health's computer systems including EPIC E.H.R and other information systems, Knowledge of adult learning, instructional design, and curriculum development techniques including use of multimedia / E-Learning learning database systems, with the ability to instruct and conduct training programs and sessions, Evaluate clinical authorizations for procedural/technical completeness and accuracy, Resolve authorization procedural and technical issues with attention to detail and accuracy, Query and distribute clinical data reports including but not limited to: open case reports, letter error reports, single case agreement reports, etc, Create inquiries into the CareConnect/ServiceConnect application and route to the appropriate clinical department for decision making as necessary, Provide professional, accurate and appropriate feedback to management regarding trends and training opportunities, Excellent problem solving and analytical skills; strong verbal, written, and interpersonal communication skills, Knowledge of Medicaid/HP transmission and claims processes preferred, High level of proficiency with Microsoft Office Products (Word, Excel, Outlook, PowerPoint), Participation and successful completion of the Clinical Review Specialist training program, Review and authorize major dental services based on medical necessity and eligibility, in accordance with contract language, Consistently meet Level 1 productivity requirements (16+ authorizations per hour after 6 months), Maintain acceptable audit and IRR scores within departmental guidelines, Represent DentaQuest in a professional manner at all times, Ability to read and interpret x-rays, dental models, photos, and/or patient charts, Efficient PC skills (Word, Excel, Access), Ability to remain organized with multiple interruptions, 6 months of dental assisting experience or degree in dental field; previous dental insurance experience, Assists Care Coordination by researching patient information as assigned, Reviews and manages claims reports and other incoming patient information for the purpose of making care coordination referrals and providing patient care within the role and scope of the position, Completes auditing reports and queries to ensure the closure of gaps and for the identification of opportunities for improvement, Performs all assigned duties as directed by supervisor, Ensures duties are adequately performed as needed or seeks out supervisor for guidelines, Maintains certification and BLS certifications, Demonstrates the ability to develop and build strong computer skills in a variety of software products to include but not limited to EMR documentation and functionality, Microsoft products to include Visio, other products used to support Beacon Health, Assure patients get appropriate and timely services by working with the care coordinator and the patient's provider office, by making referral requests as needed and by motivating/teaching people to seek care at the appropriate location and level of care, Bridge community, cultural, linguistic and educational barriers to encourage patient self-care and participation in the management of their care, Participate and attend regularly scheduled staff meetings and other assigned meetings, Assumes and completes all other duties as assigned by regional manager or designee, Appropriately reviews and triages denials for A/R, billing, downgrade, appeal, or denial adjustment, Able to prioritize and manage caseload without jeopardizing timely filing, Demonstrates excellent technical and clinical skills by drafting credible, defensible appeals, Conducts thorough evidence-based clinical literature research to support appeals, as needed, Understands and files appropriate levels of appeal (ie: reconsideration, dispute, appeal, ALJ…), Appropriately utilizes claim and medical informatics for the purposes of developing, tracking, and trending denials and appeals, Ability to perform all other duties as assigned or requested, Communication – communicate clearly and concisely, verbally and in writing; utilize appropriate method/tool to communicate with other departments as necessary, Interpersonal skills - able to work effectively with other employees and external parties, Policies & Procedures - demonstrate knowledge and understanding of organizational policies, procedures and systems; ensure confidentiality of all patient accounts by following HIPAA guidelines, Time management and organization - perform work under tight guidelines, must be detail oriented and well organized. 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