Clinical Reviewer in Santa Ana, CA at Parallon

Date Posted: 3/11/2018

Job Snapshot

  • Employee Type:
  • Location:
    1508 Brookhollow Drive
    Santa Ana, CA
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:

Job Description


1.      Performs TAR reviews and completion of TAR requests according to Medi Cal format and deadlines

2.      Performs Medi Cal clinical medical file review of hospital documentation for necessary clinical treatment and patient severity of illness to warrant admissions and continued acute inpatient level of care

3.      Performs on line documentation of clinical justification for hospital stays and pre screening of files to determine if Appeal is warranted.

4.      Documents clinical justification for Appeal requests

5.      Conducts clinical review of cases that do not meet criteria

6.      Performs clinical intake and reviews cases according to the policies and procedures of company.

7.      Collects and enters confidential information ensuring the highest level of confidentiality in all areas.

8.      Maintains written documentation according to company’s documentation policy

9.      Provides ongoing to TAR related to company’s Clinical Review process
Assists in the orientation and training of new clinical TAR staff in department.

10.  Participates and understands scope of responsibility in all ongoing of the  TAR Process.

11.  Knowledge of care management plans and services in order to implement that knowledge in a clinical in-patient setting.

12.  Knowledge of care management plans and services in order to implement that knowledge in a clinical setting.

13.  Ability to use independent judgment related to medical record review.

Job Requirements


• RN from an accredited school of nursing

• Current, active California RN license
• 3-4 years experience in acute care environment
• 5 years previous utilization management experience in a managed care

                    and/or hospital setting

• Computer proficiency

*An associate or bachelor's degree in nursing or a hospital-sponsored diploma


*Knowledge and proficiency of established clinical standards and

                    guidelines with Medi-Cal

• Good organizational skills preferred

                    *Experience in both nurse review and assisting with the utilization review

                    appeals process.