Clinical Review Specialist

The Kestra team has over 400 years of experience in the external and internal cardiac medical device markets. The company was founded in 2014 by industry leaders inspired by the opportunity to unite modern wearable technologies with proven device therapies. Kestra’s solutions combine high quality and technical performance with a wearable design that provides the greatest regard for patient comfort and dignity. Innovating versatile new ways to deliver care, Kestra is helping patients and their care teams harmoniously monitor, manage, and protect life.

The Clinical Review Specialist (CRS) is responsible for reviewing physician treatment orders and interpretation of medical records and clinical documentation to help ensure information submitted to health insurance companies meet their published criteria for approval treatment by Durable Medical Equipment (DME). Ensure that details of the patient's condition, physician orders, course of treatment are well supported by clinical documents accompanying the prescription Order Packet. Ability to understand and analyze health insurance plan language documentation and utilize pre-approved criteria/guidelines and insurance plan language to validate necessity/appropriateness of treatment (i.e. Medical Policy Plan Language).

ESSENTIAL DUTIES:

• Review different types of clinical documentation including, but not limited to, medical records, EOBs, appeal letters, and denial/approval letters
• Ensure that details of the patient's condition, physician orders, course of treatment and well supported rationale are present within the clinical reviewer’s final review
• Review and interpret medical records to appeal denied insurance and Medicare claims
• Apply clinical judgement and knowledge for level of care and medical necessity reviews. Will assist with the submission of Prior Authorizations to health insurance companies
• Draft Appeals for PA Denied due to Medical Reasonableness and Necessity
• Confirm that the correct template (medical argument) is used
• Confirm letter is well written and logically structured
• Confirm all attachments are listed properly and included with appeal letter
• Verify that the number of pages coincide with what is scanned to the server
• Perform various computer functions including saving, copying, pasting, scrolling, etc.
• Liaison with legal and regulatory departments regarding training materials processes
• Participate in on-call and off hours coverage. Hours on-call and worked may include evenings, weekends, and holidays
• Adhere to Pledge of Confidentiality
• Information regarding a patient of this company shall not be released to any source outside of this company without the signed permission of the patient. Furthermore, information will only be released internally on a need-to-know basis. All Team Members will not discuss patient cases outside the office or with anyone not employed by this company unless they are directly involved with the patient’s case

COMPETENCIES:

• Passion: Contagious excitement about the company – sense of urgency. Commitment to continuous improvement.
• Integrity: Commitment, accountability, and dedication to the highest ethical standards.
• Collaboration/Teamwork: Inclusion of Team Members regardless of geography, position, and product or service.
• Action/Results: High energy, decisive planning, timely execution.
• Innovation: Generation of new ideas from original thinking.
• Customer Focus: Exceed customer expectations, quality of products, and experience always present of mind.
• Emotional Intelligence: Recognizes, understands, manages one’s own emotions and is able to influence others. A critical skill for pressure situations.
• Passionate about the heart-failure space and a strong desire to make a difference.
• Has a deep passion for solving problems of healthcare with enthusiasm for building positive working relationships and winning as a team.
• Ability to analyze clinical documentation in relation to utilization reviews.
• Ability to interpret and apply appropriate guidelines to utilization reviews.
• Ability to understand and contribute to commercial goals.
• Enjoys taking complex processes and breaking them down into simple and repeatable processes

Requirements

Education/Experience Required:

• Bachelor’s degree
• 2+ years of experience in electrophysiology, cardiology, nursing, and/or medical device field
• Licensed as a Registered Nurse, Nurse Practitioner, Physicians Assistant, Medical Assistant, or other healthcare delivery credentials
• Competency in Microsoft tools (Outlook, Excel, Teams)
• Experience in patient and/or clinical education
• Ability to