Clinical Reviewer/RN Work From Home

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Requisition ID: 127077
Job Category: Call Center
Location: United States-Alabama-Mobile-5441 Highway 90 West Suite 1 Mobile 36619
Posted Date: 11/14/2017 2:00:51 PM


Responsible for review of  medical records to evaluate the clinical documentation, conditions or procedures to support the scheduled modality as required by the health care facility and Alorica. Ensure patient care provided meets the highest standards of safety, effectiveness, and patient rights.

Essential Duties & Responsibilities

  • Review of medical records for patients scheduled for an outpatient visit requiring the expertise of a Registered Nurse (RN) to evaluate medical need, clinical evaluation and RN P2P escalation review with the Payor(s) to secure the authorization prior to the patients’ date of service
  • Provide guidance and direction to Patient Access staff based on review of the scheduled modality to complete pre-authorization requirements for patients.
  • Document pertinent patient information and all account work activity in the appropriate systems required by the health care facility and Alorica.
  • Maintain a professional relationship with the patient while providing excellent customer service and performing assigned duties.
  • Responsible for accurately obtaining and entering proper procedure or diagnosis codes into scheduling system.
  • Review work and ensure accuracy of data such as patient type, code identification, insurance, and demographic information to minimize error rate and time delays in clinical and billing departments.
  • Responsible for understanding and complying with all policies, procedures, and regulations relating to job duties, including Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Occupational Safety and Health Administration (OSHA), Medicare and Medi-Cal.
  • Perform other duties as assigned by management.

Qualifications & Requirements

  • Bachelor’s Degree and Registered Nurse certification required.
  • 5 years’ experience or more of acute care experience
  • 2 years’ experience or more of oncology experience (preferred)
  • Oncology Certified Nursing (OCN) (preferred)
    Knowledge, Skills, Abilities & Other Characteristics: 
  • Bilingual (English/Spanish) preferred.
  • Knowledge of hospital billing requirements and the documentation necessary to satisfy those requirements.
  • Experience with medical terminology, data entry, admission process, business office, cash collections, physician office interactions, and public interactions preferred.
  • Working knowledge of Protected Health Information (PHI) and Health Insurance Portability and Accountability Act (HIPAA).
  • Knowledge and understanding of insurance guidelines and protocols, components of full verification, and payer information / requirements.
  • Exhibit competency in the use of all registration systems, electronic verification tools, and web based resources.
  • Proficient personal computer skills including Microsoft Office.
  • Excellent interpersonal, written, and oral communication skills.
  • Ability to prioritize and organize work in a multitasked environment.
  • Ability to adapt to a flexible schedule.
  • Ability to maintain the highest level of confidentiality.


Position Scope

  • Supervisory/Management Responsibility: N/A
  • Relationships:
    • Internal – Departmental Managers and Supervisors, Non-Management.
    • External – Hospital Staff, Insurance Company Staff.


Work Environment

  • Office environment.
  • Ability to lift and/or move 20 pounds with or without accommodation.
  • Ability to travel.
The preceding job description has been designed to indicate the general nature and level of work performed by employees within this classification.  It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job. Employer reserves the right to modify this job description, including by adding, removing, and altering job duties.
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