Nurse Clinical Analysis Reviewer in Santa Ana, CA at Parallon

Date Posted: 4/25/2018

Job Snapshot

Job Description


The HCA Nurse Reviewer-provides clinical analysis necessary to Appeal Adjudications where medical necessity was not substantiated during initial Authorization submission. In addition, the Nurse Reviewer will assist with the clinical development of staff and act as a Clinical Specialist as needed to support client overflow.


•         Responsible for completing Clinical Reviews and Summaries as needed under the following circumstances:

o   Restricted Daily Utilization Reviews

o   Appeals for Denied/Modified Adjudications

•         Assists with clinical and system training and the monitoring of new hire progress during probation period(s)

•         Assist with clinical questions that do not require Clinical Supervisor intervention

•         Conducts Quality Assurance checks of accounts from both a clinical perspective

•         Acts as back-up in times of account overflow for clinical submissions

•         Assists with the research needed to implement new clients based on state specific requirements

•         Communicate issues to management affecting the overall quality of the teams.

•         Promotes and maintains harmonious and effective relationships and communications with other departments and clients.

•         Manages individual Appeal(s) caseload

o   Must meet client specified deadlines for submission and/or communicate barriers

  • Accomplishes staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching, counseling, disciplining and conducting annual reviews of employees; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards
  • Performs other duties as assigned


Job Requirements

Education, Training, Experience:

•         Must have a current Nursing License- (LVN, RN) in the state of California.

  • Proficient with computer and basic software including Excel, Word and Outlook.
  • Basic knowledge of office equipment use and maintenance including network printer, copier, postage machine, fax machine.

Skills or Other Qualifications:

  • Excellent written and oral communication skills.
  • Clinical documentation must be thorough but concise.
  • Must pay attention to detail and accuracy.
  • Ability to work effectively both independently and as part of a team.
  • Strong customer service skills required
  • Must have meeting facilitation and presentation skills.
  • General business office knowledge.
  • Analytical ability a plus.
  • Must be organized. 
  • Must have current CA Nursing license.
  • Must understand basic principles of Case Management and Utilization Management concepts.