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Clinical Services Specialist II
Conifer Health Solutions
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Clinical Services Specialist II
Conifer Health Solutions
Details
Salary:
Open
Discipline:
General Nursing
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 II is a member of a multi-disciplinary team that is responsible for reviewing patient medical records to determine medical necessity. The Clinical Specialist II 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. When required the Clinical Specialist II is to 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. In addition, the Clinical Specialist II is a super user, being able to access multiple hospital and insurance systems and able to complete reviews for multiple service types. The Clinical Specialist II is also able to assist with various additional responsibilities beyond medical necessity reviews, as assigned by department leaders.
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 a minimum of 2 major service type reviews. (e.g. Pre-Admission, Admission, Payor Notification, Continued Stay, or Retro-Authorization reviews per policy and procedure).
- Responsible for promptly communicating with the team and leaders as requested regarding projects or cases assigned.
- Frequently assess Case Tracker queue as assigned; making appropriate assignment adjustments to ensure cases are reviewed and worked in an efficient and timely manner.
- Conduct routine reports that assess department performance and communicate updates promptly to leadership. Handoff shift at end of shift which should include updates about current team member assignments, technical events, and case volume.
- Assist with training and audit support as assigned.
- Communicate via phone to Clinical Specialist I any important information related to changes and updates.
Qualifications:
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.
- Ability to lead and coordinate activities of a diverse group of people
- 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
- Ability to quickly adjust workflow to meet the demands of the department
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience preferred to perform the job.
- Three (3) years bedside experience in the relevant clinical specialty preferred (e.g., care managers for pediatric patients should have pediatric nursing experience)
- Conversant knowledge and experience with case management care coordination, and/or utilization review
- Has fully functioned as a Clinical Specialist I for a minimum of 9 months, meeting or exceeding the minimum performance expectations of the position
- Possesses ability and confidence in collaborating with Leaders and Quality Analysts within the Clinical Services Department
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
- May be expected to maintain department operations in the absence of a Supervisor, commonly before or after normal business hours
Job: Conifer Health Solutions Primary Location: Frisco, Texas Job Type: Full-time Shift Type: Days
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.
Internal Number: 2105001314
About Conifer Health Solutions
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.
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Clinical Services Specialist II
Conifer Health Solutions
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 II is a member of a multi-disciplinary team that is responsible for reviewing patient medical records to determine medical necessity. The Clinical Specialist II 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. When required the Clinical Specialist II is to 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. In addition, the Clinical Specialist II is a super user, being able to access multiple hospital and insurance systems and able to complete reviews for multiple service types. The Clinical Specialist II is also able to assist with various additional responsibilities beyond medical necessity reviews, as assigned by department leaders.
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.
Qualifications: 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.
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience preferred to perform the job.
REQUIRED CERTIFICATIONS/LICENSURE
Include minimum certification required to perform the job.
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.
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.
Job: Conifer Health Solutions Primary Location: Frisco, Texas Job Type: Full-time Shift Type: Days 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.
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