Job Description

Job Description

Job Description

CMA/Clinical Reviewer needed for busy medical practice in Myrtle Beach. Must have excellent computer and customer service skills. Hours are Monday through Thursdays 7:45am - 5:15pm and Fridays 8am - 12pm. No nights or weekends! Excellent pay and benefits including paid holidays, PTO and sick time, medical, dental, vision, short-term disability, company paid life insurance, pre-paid legal, identity theft, and 401k offered.

GENERAL SUMMARY OF DUTIES:

When ancillary or lab services are ordered by providers but do not meet the “medically necessary” requirements per insurance guidelines, the CMA/Clinical Reviewer will review the patient’s chart to ensure that all information is accurate and look for other diagnosis’ alternatives to support the orders being medically necessary. The CMA will contact the provider to review the encounter/order. If appropriate and approved by the provider, CMA may amend the order and/or encounter on behalf of the provider to reflect the updated diagnosis and send to the provider to sign off and approve.

This position will also be reviewing service schedules (Ultrasound, Dexa Scan, etc.) prior to the scheduled appointments to ensure that appropriate guidelines and approvals have been met for the services before they are rendered to ensure that the claims will be accepted and paid quickly by payers.

ESSENTIAL FUNCTIONS

GENERAL DUTIES:

1. Reviews medical records to ensure all activities/interventions, patient/family responses, medication dispensed/prescribed, etc., is accurate and up to date.
2. CMA/Clinical Reviewer will be primary source/point of contact for providers regarding medical necessity requirements for payors.
3. CMA/Clinical Reviewer will work with Insurance Coordinator on medical necessity issues.
4. Adheres to infection control/safety guidelines, and confidentiality policies.
5. Reviews orders that are missing medically necessary diagnosis according to the patient’s insurance and comparing this to the LCD and NCD guidelines, and correcting as needed.
6. Ensures that patient charts are meeting the appropriate coding standards with regards to government agencies and insurance companies.
7. May be required to fill in as an outpatient clinical CMA from time to time if there is a staffing need.

KNOWLEDGE:

1. Knowledge of basic nursing principles and protocols.
2. Knowledge of policies and procedures related to patient confidentiality.
3. Knowledge of medical chart reporting/records.
4. Knowledge of different types of insurance packages.
5. Knowledge of insurance company requirements related to patient care.
6. Knowledge of EMR systems and technical proficiency.
7. Knowledge of Medical terminology.
8. Knowledge of coding/ ICD codes.
9. Knowledge of clinical processes, rooming patients, taking vitals, and clinical patient care.

SKILLS:

1. Skill in appropriate assessment and assistance techniques.
2. Skill in appropriate use of universal precautions, safe workplace environment, and confidentiality methods.
3. Skill in health information management by appropriately charting patient data.
4. Organizational skills and time management required.

ABILITIES:

1. Ability to work effectively as team members with physicians and other staff.
2. Ability to appropriately interact with patients, families, staff, and others and communicate effectively and professionally at all times.
3. Ability to flexibly respond to changing demands.
4. Ability to work in a demanding environment that can be stressful at times.
5. Ability to pay attention to detail.
6. Ability to critically think and problem-solve.
7. Ability to understand complex medical terminology, anatomy, and pathophysiology.
8. Ability to work independently for extended periods of time.

REQUIREMENTS:

1. National Certification as a certified medical assistant, with an accredited entity.
2. Strong organization and interpersonal skills
3. Strong computer proficiency
4. Strong understanding of basic math

ENVIRONMENTAL/WORKING CONDITIONS:

Combination of office and remote work.

PHYSICAL/MENTAL DEMANDS :

Varied activities include sitting, walking, stooping, lifting, bending, and reaching. Occasional stress from workload. Must be able to use a variety of office equipment including phone, writing instruments, PC, fax.

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