SMA Careers >> Clinical Review Specialist
Clinical Review Specialist
Summary
Title:Clinical Review Specialist
ID:4598
Department:Performance Improvement
Location:150 Magnolia Ave., Daytona Beach, FL
Description
Working Hours: 40 hrs week; Mon-Fri-8am-5pm
Non-exempt

This position audits performance indicators and outcomes for the professional review of clinical services and activities documented in the client record. The incumbent will ensure that client placement and service delivery complies with the UM standards of SMA. In addition to chart audits the candidate may engage in a variety of Performance Improvement and Quality Assurance activities as assigned, including but not limited to assisting with external audit preparation and participation such as CARF and LSF audits.

Compliance responsibilities include but are not limited to assessing the quality of the documentation in the client record and ensuring this documentation complies with relevant Florida Administrative Codes, requirements in the Medicaid Manual, CARF standards, HIPAA, and SMA departmental policies and procedures. Additional responsibilities include staff training to remediate identified areas of non-compliance. This position is accountable for maintaining performance measurement information within a database and providing outcome reports to program directors and management. Additional tasks may include participation in various Performance Improvement and Quality Assurance activities.  Work assignment locations will vary.

Qualifications

Graduation from an accredited school with a minimum of a bachelor’s degree preferably in a human services area; Master’s degree preferred and/ or any equivalent combination of training and experience which provides the following knowledge, skills and abilities. Certification in CARF surveying preferred. Experience working in behavioral health with data collection and auditing.
 
  • Knowledge in behavioral health, knowledge of current practices and documentation requirements regarding the care and treatment of the population served.
  • Knowledge of administrative and data systems, procedures and processes for improving program effectiveness and efficiency.
  • Knowledge of data collection, compilation and reporting. 
  • Ability to prepare clear and concise reports. Some knowledge of state regulatory policies and accreditation standards pertaining to mental health service delivery.
  • Ability to train, consult, and present improvement recommendations to staff, committees, and others.
  • Ability to evaluate and analyze systems problems and make recommendations for corrective actions.
  • Skill in time and organizational management;
  • Ability to complete work under strict time lines, while maintaining flexibility to assist with emergent issues/concerns;
  • Ability to quickly assess situations and use sound judgment;
  • Ability to identify services needed by clients during the rehabilitation process;
  • Ability to follow both written and oral instructions and complete tasks as instructed;
  • Ability to express oneself clearly and concisely both orally and in writing;
  • Ability to communicate clearly and train staff effectively;
  • Ability to establish and maintain effective working relationships with co-workers, medical and clinical professionals, and the general public.  

Responsibilities
 
  • Audits the extent to which the medical record is current, accurate, and meets all documentation requirements in accordance with CARF, HIPAA, Medicaid, Children & Families, and SMA standards.
  • Ensures that documentation in the medical record adequately supports billing requirements for the service(s) delivered. 
  • Identifies and reports deficiencies in these areas to staff/management as appropriate.
  • Assists with collection of program-specific outcome measure information. Conducts quarterly random audits of each program. Identifies and reports weaknesses and deficiencies by individual staff and program area and provides remedial training and follow-up.
  • Performs concurrent reviews as assigned by Clinical Compliance Director of client records to certify appropriateness of admission and continued stay and discharge planning.
  • Performs retrospective reviews as assigned by Clinical Compliance Director of client records to certify appropriateness of discharge/referrals.
  • Writes and distributes to staff, legible, informative, and understandable notices of non-compliance issues identified through reviews of client records with copies to their supervisors.
  • Acts as an advisor to the staff and program supervisors through in-service trainings, individual meetings and written communications of issues pertaining to the documentation expectations of insurance companies and other third party payors.
  • As assigned, submits a monthly written report detailing the number and percentages of authorizations for each level of care.
  • Reports, on a monthly basis the type of documentation problems that are causing denial of payment for services provided.
  • Improves professional knowledge and skill base relevant to utilization management by attending seminars, trainings, and conferences and by reading current literature.
  • Participates in required SMA in-service trainings to maintain employment.
  • Provides assistance with a wide variety of correspondence and reports related to the work  
  • Maintains an awareness of proper safety procedures and guidelines and applies these in performing daily activities and tasks.
  • Serves as a liaison for external audits and reporting
  • Reviews the monthly UM/UR compliance monitoring results and corrective action plans to ensure standards are met.
  • Acts as liaison between SMA staff and insurance companies, funding sources, or their managed care organizations when client’s the health care is being managed under a managed care plan.
  • Assist the Clinical Compliance Director and performs related work as required or assigned.
  • Abides by principles of EEO compliance and a workplace of dignity and respect.
  • Works cooperatively in a group/team setting.
  • Shows respect to others.
  • Takes guidance and direction from supervisors.
  • Arrives/Reports to work on time and ready to work.
 
SMA Healthcare is a tobacco and drug-free workplace.
EEO Employer     W / M / Vet / Disabled
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