Act as liaison between managed care organizations and the facility professional clinical staff. * Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ...
Act as liaison between managed care organizations and the facility professional clinical staff. * Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ...
Medical Assistant, Research Assistant
$17.50 - $22.25/hr
Review and understand study protocols, inclusion and exclusion criteria, visit schedules, and study-specific requirements. * Support compliance with FDA, Sponsor, IRB, and Good Clinical Practice ...
Medical Assistant, Research Assistant
$17.50 - $22.25/hr
Review and understand study protocols, inclusion and exclusion criteria, visit schedules, and study-specific requirements. * Support compliance with FDA, Sponsor, IRB, and Good Clinical Practice ...
Medical Assistant, Research Assistant
San Juan, PR ยท On-site
$17.50 - $22.25/hr
Review and understand study protocols, inclusion and exclusion criteria, visit schedules, and study-specific requirements. * Support compliance with FDA, Sponsor, IRB, and Good Clinical Practice ...
Medical Assistant, Research Assistant
San Juan, PR ยท On-site
$17.50 - $22.25/hr
Review and understand study protocols, inclusion and exclusion criteria, visit schedules, and study-specific requirements. * Support compliance with FDA, Sponsor, IRB, and Good Clinical Practice ...
Remote Administrator on Call PR
Guaynabo, PR ยท On-site +1
... clinical management, allocation, recovery, and overall coordination of donor-related actions. The ... Engages in review, education, and required organizational meetings to promote best practice sharing ...
Remote Administrator on Call PR
Guaynabo, PR ยท On-site +1
... clinical management, allocation, recovery, and overall coordination of donor-related actions. The ... Engages in review, education, and required organizational meetings to promote best practice sharing ...
Board Certified Radiation Oncologist, MD, Part -Time, Puerto Rico
San Juan, PR ยท On-site
$206.64 - $275.52/hr
Complete VA clinical documentation in CPRS and participate in required peer reviews. Comply with all VA credentialing, privileging, and annual training requirements. 1. Clinical Requirements * MD or ...
Board Certified Radiation Oncologist, MD, Part -Time, Puerto Rico
San Juan, PR ยท On-site
$206.64 - $275.52/hr
Complete VA clinical documentation in CPRS and participate in required peer reviews. Comply with all VA credentialing, privileging, and annual training requirements. 1. Clinical Requirements * MD or ...
Pharmacist Call Center - San Juan, PR
San Juan, PR ยท On-site
$57 - $68.75/hr
The Clinical Pharmacist will report to the Operations Team Leader. This role is primarily responsible for performing telephonic consultations with members to complete comprehensive medication reviews ...
Pharmacist Call Center - San Juan, PR
San Juan, PR ยท On-site
$57 - $68.75/hr
The Clinical Pharmacist will report to the Operations Team Leader. This role is primarily responsible for performing telephonic consultations with members to complete comprehensive medication reviews ...
... clinical management, allocation, recovery, and overall coordination of donor-related actions. The ... Engages in review, education, and required organizational meetings to promote best practice sharing ...
... clinical management, allocation, recovery, and overall coordination of donor-related actions. The ... Engages in review, education, and required organizational meetings to promote best practice sharing ...
Per Diem Runner PR
Guaynabo, PR ยท On-site
Fax clinical documentation to UNet, Transplant Centers and/or to the Administrator-on-call, as ... For further information, please review the Know Your Rights notice from the Department of Labor.
Per Diem Runner PR
Guaynabo, PR ยท On-site
Fax clinical documentation to UNet, Transplant Centers and/or to the Administrator-on-call, as ... For further information, please review the Know Your Rights notice from the Department of Labor.
P.R In house ONLY Salaried Pharmacist Centralized Services (80 hours)
Guaynabo, PR ยท On-site
$101K - $123K/yr
Responsible for performing clinical and professional pharmaceutical work in the review, processing, compounding and dispensing of prescribed medications, drugs, and supplies needed for patient care.
P.R In house ONLY Salaried Pharmacist Centralized Services (80 hours)
Guaynabo, PR ยท On-site
$101K - $123K/yr
Responsible for performing clinical and professional pharmaceutical work in the review, processing, compounding and dispensing of prescribed medications, drugs, and supplies needed for patient care.
Complete VA clinical documentation in CPRS and participate in required peer reviews. Comply with all VA credentialing, privileging, and annual training requirements. Requirements 1. Clinical ...
Quick apply
Complete VA clinical documentation in CPRS and participate in required peer reviews. Comply with all VA credentialing, privileging, and annual training requirements. Requirements 1. Clinical ...
Clinical documentation review Proficiency with: ICD-10-CM ; CPT ; HCPCS ; Medical terminology ; Anatomy and physiology ; EHR systems (such as Epic, MEDITECH, eClinicalWorks, 3M Encoder); Microsoft ...
Clinical documentation review Proficiency with: ICD-10-CM ; CPT ; HCPCS ; Medical terminology ; Anatomy and physiology ; EHR systems (such as Epic, MEDITECH, eClinicalWorks, 3M Encoder); Microsoft ...
The company has delivered more than 15 million sessions of mental health care, published more than 35 peer-reviewed studies, and delivered unmatched outcomes in terms of access, clinical ...
Quick apply
The company has delivered more than 15 million sessions of mental health care, published more than 35 peer-reviewed studies, and delivered unmatched outcomes in terms of access, clinical ...
The company has delivered more than 15 million sessions of mental health care, published more than 35 peer-reviewed studies, and delivered unmatched outcomes in terms of access, clinical ...
The company has delivered more than 15 million sessions of mental health care, published more than 35 peer-reviewed studies, and delivered unmatched outcomes in terms of access, clinical ...
... reviews and adherence-related outreach * Assess medication regimens for safety, effectiveness, and adherence * Provide clinical recommendations related to gaps in care, drug interactions, high-risk ...
... reviews and adherence-related outreach * Assess medication regimens for safety, effectiveness, and adherence * Provide clinical recommendations related to gaps in care, drug interactions, high-risk ...
$89K - $116K/yr
Demonstrates independence in performing supervisory responsibilities that include, but are not limited to, assigning work to employees, monitoring workload and clinical volume, reviewing work of ...
$89K - $116K/yr
Demonstrates independence in performing supervisory responsibilities that include, but are not limited to, assigning work to employees, monitoring workload and clinical volume, reviewing work of ...
$89K - $116K/yr
Demonstrates independence in performing supervisory responsibilities that include, but are not limited to, assigning work to employees, monitoring workload and clinical volume, reviewing work of ...
$89K - $116K/yr
Demonstrates independence in performing supervisory responsibilities that include, but are not limited to, assigning work to employees, monitoring workload and clinical volume, reviewing work of ...
PR ยท On-site
... reviews and maintains data related to treatment, care and/or related services 8. Establish case ... Experience: ยท Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field ...
Quick apply
PR ยท On-site
... reviews and maintains data related to treatment, care and/or related services 8. Establish case ... Experience: ยท Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field ...
Primary Care Physician - Relocation to Tucson, Arizona
San Juan, PR ยท On-site
$240K - $260K/yr
... review, and special projects as required.- Adhere to HIPAA regulations and maintain the ... clinicians.Required Skills and Experience:- Preferably 2 years of experience as an Internal ...
Quick apply
Primary Care Physician - Relocation to Tucson, Arizona
San Juan, PR ยท On-site
$240K - $260K/yr
... review, and special projects as required.- Adhere to HIPAA regulations and maintain the ... clinicians.Required Skills and Experience:- Preferably 2 years of experience as an Internal ...
$38/hr
Strong experience in reviewing and approving deviations, critical utilities, and environmental ... Kelly Science & Clinical is your connection to premier scientific and clinical companies looking to ...
Quick apply
$38/hr
Strong experience in reviewing and approving deviations, critical utilities, and environmental ... Kelly Science & Clinical is your connection to premier scientific and clinical companies looking to ...
Experience in batch record review, audit trail reviews and GDP with focus on data integrity (ALCOA ... Kelly Science & Clinical is your connection to premier scientific and clinical companies looking to ...
Quick apply
Experience in batch record review, audit trail reviews and GDP with focus on data integrity (ALCOA ... Kelly Science & Clinical is your connection to premier scientific and clinical companies looking to ...
Clinical Reviewer information
What is a clinical reviewer?
Clinical reviewers are professionals who evaluate medical records, clinical data, or healthcare documentation to ensure accuracy, compliance, and quality of care. They may work in settings such as hospitals, insurance companies, or regulatory agencies to review cases for appropriateness of care, adherence to clinical guidelines, or for billing and coding accuracy. Clinical reviewers often have backgrounds in nursing, medicine, or another healthcare field and use their expertise to make informed assessments. Their work is critical for improving patient outcomes, supporting proper reimbursement, and maintaining regulatory standards.
What does a clinical reviewer do?
A clinical reviewer monitors healthcare documents to ensure compliance before submitting to insurance companies. You handle the daily responsibilities of checking medical records for appropriate criteria and providing the proper documentation. You collaborate with providers to ensure all information is accurate. Your duties are also to review requests for services, research and gather further information when necessary, perform an information audit, and evaluate procedures for approval. You also record, analyze, and report data elements that could help improve the quality of care of a patient.
What skills are required for a clinical reviewer?
To thrive as a Clinical Reviewer, you need a strong background in healthcare or life sciences, often supported by a relevant degree and experience in clinical settings. Familiarity with medical terminology, regulatory requirements, and systems such as electronic medical records (EMRs) or clinical trial management software is typical. Attention to detail, analytical thinking, and effective written communication are standout soft skills for this role. These skills ensure accurate evaluation of clinical data, compliance with standards, and clear reporting, which are critical for patient safety and regulatory approval.
What are some common challenges clinical reviewers face when evaluating medical records, and how can they be addressed?
Clinical Reviewers often encounter challenges such as incomplete documentation, inconsistent terminology, and tight deadlines when evaluating medical records. To overcome these issues, it's important to develop strong attention to detail, stay current with medical coding standards, and communicate effectively with healthcare providers to clarify ambiguities. Collaborating closely with clinical teams and leveraging electronic health record (EHR) systems can also help streamline the review process and ensure accuracy.
What is the difference between Clinical Reviewer vs Medical Reviewer?
| Aspect | Clinical Reviewer | Medical Reviewer |
|---|---|---|
| Required Credentials | RN, LPN, or other healthcare licenses; sometimes certifications in case management or clinical review | MD or DO; medical license; often board-certified in a specialty |
| Work Environment | Insurance companies, healthcare organizations, or government agencies; reviewing medical records and claims | Hospitals, clinics, insurance companies; evaluating medical records and providing expert opinions |
| Employer & Industry Usage | Primarily in insurance and healthcare administration | Primarily in insurance, healthcare, and legal settings |
Both Clinical Reviewers and Medical Reviewers assess medical information, but Clinical Reviewers typically hold nursing or allied health credentials and focus on case management and claims review. Medical Reviewers are licensed physicians who provide expert medical opinions. The roles often overlap in insurance and healthcare industries, but their credentials and scope of practice differ.
More about Clinical Reviewer jobs
What are the most commonly searched types of Clinical Reviewer jobs in Puerto Rico?
The most popular types of Clinical Reviewer jobs in Puerto Rico are:
What are popular job titles related to Clinical Reviewer jobs in Puerto Rico?
For Clinical Reviewer jobs in Puerto Rico, the most frequently searched job titles are:
What job categories do people searching Clinical Reviewer jobs in Puerto Rico look for?
The top searched job categories for Clinical Reviewer jobs in Puerto Rico are:
Full-time
Re-posted 3 days ago
Job description
Overview
PURPOSE STATEMENT:ย
Proactively monitor utilization of services for patients to optimize reimbursement for the facility. ย
ResponsibilitiesESSENTIAL FUNCTIONS:ย
- Act as liaison between managed care organizations and the facility professional clinical staff.ย
- Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.ย
- Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay. ย
- Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.ย
- Conduct quality reviews for medical necessity and services provided.ย ย
- Facilitate peer review calls between facility and external organizations. ย
- Initiate and complete the formal appeal process for denied admissions or continued stay. ย
- Assist the admissions department with pre-certifications of care. ย
- Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.ย
OTHER FUNCTIONS: ย
- Perform other functions and tasks as assigned.ย
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:ย
- Required Education: High school diploma or equivalent.ย
- Preferred Education: Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.ย
- Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferredย
LICENSES/DESIGNATIONS/CERTIFICATIONS: ย
- Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.ย
- CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.ย ย
- First aid may be required based on state or facility requirements.ย
ย
ADDITIONAL REGULATORY REQUIREMENTS:ย
While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances ย (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.ย
We are committed to providing equalย ย employment opportunities to all applicants for employment regardless of an individual's characteristics protected by applicable state, federal and local laws.
Employment Type: FULL_TIME