Job Description

Job Description

Job Description

Job Summary:

The Clinical Risk Specialist focuses on reviewing and analyzing medical record data by extracting pertinent information; and formulating detailed reports to support medical conclusions and payment integrity recommendations. The Clinical Risk Specialist works under the general direction of the Director of Clinical Services.

Duties and Responsibilities:

• Review, analyze, and interpret medical record data by extracting pertinent information.
• Analyze each claim individually to ensure adequate due diligence for our clients.
• Provide a clinical timeline that accurately documents the patient’s hospitalization by reviewing the medical records.
• Analyze and interpret hospital care charges with specific focus on room and board acuity, incidental supplies, nursing services, preventable hospital acquired conditions, pharmaceuticals, and other therapies. 
• Utilize technology for hospital charge data capture.
• Formulate detailed reports to support medical conclusions and payment integrity recommendations.
• Ensure clinical audit conclusions are incorporated into the Claim Payment Integrity 
• Review (CPIR) report utilized for adjusted claim payments by clients.
• Collaborate with other teams to ensure final clinical audits focus on specific client requests, timeframes for audit completion, and sound clinical judgement in the case of possible appeals.
• Ensure compliance with HIPAA regulations and requirements.
• Performs other duties as assigned.

Required Skills and Abilities:

• Critical thinking with emphasis on research and analytical skills
• Creative energy with resourceful problem-solving skills
• Skillful discernment and independent judgment when reviewing complex hospitalizations
• Effective verbal and written communication skills
• Professionalism and strong work ethic
• Collaborative talent and leadership experience
• Proficient in Microsoft Office Suite or similar software.
• Ability to pass a background check

Education and Experience:

• Current RN Licensure in state of operation.
• Advanced nursing degree is necessary.
• Recent adult acute care clinical experience,10-year minimum.
• Claim Audit experience is necessary.

Physical Requirements:

Individual in this position must be able to work in a standard office environment, operating standard office equipment.

Company Description

At Catalyst, our employees are instrumental to our success, and we reward them accordingly. Located in Irvine, CA, we are a specialty professional services niche company in the dynamic, fast-paced field of healthcare. We take a thorough, thoughtful approach to claims management and offer cost-containment solutions that help our clients manage risk.

As an Equal Opportunity Employer, Catalyst Health gives equal consideration to all employees and job candidates without regard to sex, age, race, marital status, sexual orientation, religion, national origin, citizenship status, physical or mental disability, political affiliation, service in the Armed Forces of the United States, or any other characteristic protected by federal, state, or local law.

Company Description

At Catalyst, our employees are instrumental to our success, and we reward them accordingly. Located in Irvine, CA, we are a specialty professional services niche company in the dynamic, fast-paced field of healthcare. We take a thorough, thoughtful approach to claims management and offer cost-containment solutions that help our clients manage risk.\r\n\r\nAs an Equal Opportunity Employer, Catalyst Health gives equal consideration to all employees and job candidates without regard to sex, age, race, marital status, sexual orientation, religion, national origin, citizenship status, physical or mental disability, political affiliation, service in the Armed Forces of the United States, or any other characteristic protected by federal, state, or local law.

Job Tags

Work at office, Local area,

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