12 Clinical Review Jobs

Job Description for Senior Clinical Tool Specialist You will assist and lead in the research, creation and development of Clinical Tools and Classification Systems such as groupers, classifiers, stagers, and patient segmentation. Work in a collaborative manner with support from data analyst to data scientist to ensure our clinical tools are world class and fit for the purposes of clinical risk management (ranging from cost containment to quality and clinical pathways). Core Responsibilities Include How you would make a difference Evaluate and recommend improvements to the current clinical tools include but not limited to diagnosis related groupers, disease episode groupers, patient risk scores, disease staging tools. Evaluate and recommend improvements for relative indices such as risks scores, disease burden index and case mix that support our clinical tools. Understand the final usage of the tools and recommend relevant insights for clinical tool evolution. Provide clinical support in the analysis of claims data to derive actionable clinical insights. Participate in the application of the tools in various business processes and engage with Customers to discuss the effective usage of clinical tools. Create and assist in the development of Clinical Pathways for a range of products such as Condition Management, Hospital Optimization, Palliative Care, etc. Review the clinical appropriateness of product designers. Supporting clinical coding teams in the creation, update, and maintenance of clinical classifications Research and develop/implement various clinical terminologies and ontologies (such as SNOMED-CT, LOINC, WHO ICD-10, ICD10CM, ICD11, CPT, ATC etc.) for integration and enhancement for our clinical tooling Behavioural Skills What you need to be successful Exceptional communication skills across a wide range of stakeholders Ability to work cohesively in a team environment while balancing multiple priorities. High level of attention to detail, resilience, enthusiasm, energy, and drive Positive, can-do attitude focused on continuous improvement. Ability to take feedback and constructive criticism to drive improved delivery. Rigorous ability to problem-solve and optimize environment. Excellent co-ordination skills Technical understanding Required A working understanding of the clinical data used in healthcare is optimal as data forms the basis of our products, as such the following core understandings are required Knowledge of healthcare specific data/ health Insurance claims is a must. Reasonable competence in use of Microsoft Office suite of tools especially Excel, Access, and PowerPoint Knowledge of patient health management, provider profiling, healthcare reporting, and other key healthcare technologies, etc. Knowledge of clinical tools and coding including coders, groupers, cross walks, and classifications Jira and Confluence Knowledge Agile ways of working Understanding of Tech Products Lifecycle Strong DRG and Clinical Coding foundation Databricks knowledge Experience in clinical reviews for output sanity checks Experience in Closed File Review for missed recovery/ prevent FWA opportunities. Experience in working with Health Tech Team (Project Manager, Data Scientists, Data Analysts) The Below Understandings Are Advantageous However Not Compulsory SQL, python, and advanced excel Understanding of advanced statistics, risk adjustment and health outcome indices and metrics Knowledge of usage of data science in the healthcare space Experience in Microsoft Azure (Databricks, Synapse, Data Factory, etc.) Qualifications The following requirements are essential: Physician/MBBS degree as a clinical qualification required. Medical degree with a minimum of 5 years of post-qualification experience. Private health care experience would be an advantage. Qualifications or training in Health informatics, clinical coding or Health Administration would be very helpful.

Key Responsibilities: Manage general medicine OPD and inpatient cases Conduct daily patient rounds and assist in treatment planning Ha ndle medical emergencies and coordinate with ICU teams Maintain accurate patient records and documentation Participate in academic and clinical discussions. Consultation with the patients and about his medical history. Examining the patient medical record histories. Fresher candidates preffered.

Nurse Level 1/2A Job Group Healthcare Family Name Complaints, Grievance and Appeals Job Title Nurse Level 1/2A Functional Title Coding Reconsideration - Nurse Consultant Exemption Status Non-Exempt Family Summary/Mission Provide comprehensive clinical review of complaints and appeals filed by providers with the use of appropriate resources and guidelines to ensure cost effective delivery of health service Position Summary/Mission Supports identification and review of appropriate case types in compliance with the clinical guidelines Promotes/supports quality effectiveness of Healthcare Services. Fundamental Components & Physical Requirements (include but are not limited to) Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation. Condenses complex information into a clear and precise clinical picture while working independently. Data gathering requires navigation through multiple system applications. Utilizes client systems to build, research and enter member information Applies clinical guidelines in determining clinical decisions Experience in patient management in clinical setting is a requirement to help with clinical understanding Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand. Documentation and Communication Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g. Claim Administrators, Plan Sponsors, and 3 rd party payers as well as Member, Family, and Healthcare Team Members respectively) Protects the confidentiality of member information and adheres to company policies regarding confidentiality Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines. Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated. Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions. Ability to understand and interpret clinical laboratory results and familiarity with clinical conditions and its management is required

EVBV Roles also open Apply now Mumbai and Hyderabad! Location : Mumbai Roles: Prior Authorization& EVBV Salary: Up to 5.75 LPA Experience: Minimum 1 year in Prior Auth Degree: Mandatory Relieving Letter: Mandatory Notice Period: 0- 60 Days Interested candidates can share your updated resume to HR Sumalika - 9030461574 (share resume via WhatsApp) Refer your friend's / Colleagues Prior authorization- Quality Assurance role for Hyderabad Eligibility: Min 4yrs into Prior Auth and 1 year as a Prior Auth QA On Or Off Papers is fine but must have QA exp only Note :- Candidate must have work experience in clinical review process. Package :- Upto 47K Take-home Location :- Hyderabad. Qualification :- Inter & above Shifts & Timings :- Night Shifts - 6:30 PM to 3:30 AM 2 Way Cab - Upto 30 KMS Radius Notice Period :- Need Immediate Joiners Only, as the relieving letter is not mandate Interview Mode :- Virtual Interview Rounds :- 1 Ops Round Interested candidates can share your updated resume to HR Sumalika - 9030461574 (share resume via WhatsApp) Refer your friend's / Colleagues

Job Description for Senior Clinical Tool Specialist You will assist and lead in the research, creation and development of Clinical Tools and Classification Systems such as groupers, classifiers, stagers, and patient segmentation. Work in a collaborative manner with support from data analyst to data scientist to ensure our clinical tools are world class and fit for the purposes of clinical risk management (ranging from cost containment to quality and clinical pathways). Core Responsibilities Include How you would make a difference Evaluate and recommend improvements to the current clinical tools include but not limited to diagnosis related groupers, disease episode groupers, patient risk scores, disease staging tools. Evaluate and recommend improvements for relative indices such as risks scores, disease burden index and case mix that support our clinical tools. Understand the final usage of the tools and recommend relevant insights for clinical tool evolution. Provide clinical support in the analysis of claims data to derive actionable clinical insights. Participate in the application of the tools in various business processes and engage with Customers to discuss the effective usage of clinical tools. Create and assist in the development of Clinical Pathways for a range of products such as Condition Management, Hospital Optimization, Palliative Care, etc. Review the clinical appropriateness of product designers. Supporting clinical coding teams in the creation, update, and maintenance of clinical classifications Research and develop/implement various clinical terminologies and ontologies (such as SNOMED-CT, LOINC, WHO ICD-10, ICD10CM, ICD11, CPT, ATC etc.) for integration and enhancement for our clinical tooling Behavioural Skills What you need to be successful Exceptional communication skills across a wide range of stakeholders Ability to work cohesively in a team environment while balancing multiple priorities. High level of attention to detail, resilience, enthusiasm, energy, and drive Positive, can-do attitude focused on continuous improvement. Ability to take feedback and constructive criticism to drive improved delivery. Rigorous ability to problem-solve and optimize environment. Excellent co-ordination skills Technical understanding Required A working understanding of the clinical data used in healthcare is optimal as data forms the basis of our products, as such the following core understandings are required Knowledge of healthcare specific data/ health Insurance claims is a must. Reasonable competence in use of Microsoft Office suite of tools especially Excel, Access, and PowerPoint Knowledge of patient health management, provider profiling, healthcare reporting, and other key healthcare technologies, etc. Knowledge of clinical tools and coding including coders, groupers, cross walks, and classifications Jira and Confluence Knowledge Agile ways of working Understanding of Tech Products Lifecycle Strong DRG and Clinical Coding foundation Databricks knowledge Experience in clinical reviews for output sanity checks Experience in Closed File Review for missed recovery/ prevent FWA opportunities. Experience in working with Health Tech Team (Project Manager, Data Scientists, Data Analysts) The Below Understandings Are Advantageous However Not Compulsory SQL, python, and advanced excel Understanding of advanced statistics, risk adjustment and health outcome indices and metrics Knowledge of usage of data science in the healthcare space Experience in Microsoft Azure (Databricks, Synapse, Data Factory, etc.) Qualifications The following requirements are essential: Physician/MBBS degree as a clinical qualification required. Medical degree with a minimum of 5 years of post-qualification experience. Private health care experience would be an advantage. Qualifications or training in Health informatics, clinical coding or Health Administration would be very helpful.

As a Medical Superintendent, you are responsible for overseeing patient clinical care, maintaining quality assurance, developing policies, ensuring compliance, and fostering a culture of continuous improvement in clinical outcomes. Your role involves a combination of clinical oversight and delivering exceptional healthcare services while driving clinical excellence. You will lead and foster a collaborative, excellence-driven multidisciplinary clinical team. Working closely with specified resources in the management team, you will ensure the identification, clinical review, and recommendations for hiring new doctors. Additionally, you will oversee medical practitioners to ensure adherence to best practices and industry standards. Your input will be crucial in establishing new clinical departments and services, developing duty rosters for all departments, and ensuring adequate staffing levels. In the realm of clinical strategy and operations leadership, you will be responsible for developing and updating SOPs for medical procedures and treatments, ensuring compliance with healthcare regulations and standards, and overseeing the day-to-day medical operations of the hospital. Engaging with external medical professionals and institutions for collaborative opportunities will also be part of your responsibilities. You will develop and implement strategies to optimize patient care while managing costs effectively, monitor key performance indicators related to clinical outcomes and patient satisfaction, and collaborate with department heads to streamline workflows and enhance clinical outcomes. Standardizing care protocols across various hospitals in groups and reducing variation in clinical deliveries will be a key focus area. Team management and development will involve ensuring appropriate clinical training for staff, supervising, advising, and counseling medical staff, and promoting a collaborative and positive work environment with clinical teams. Addressing conflicts or issues relating to consultants, technicians, and nurses to ensure high-quality patient care and ensuring ongoing professional development in line with the latest medical advancements are crucial aspects of this role. You will spearhead the implementation of clinical Health Information Systems (HIS) and ensure accurate periodic reporting of clinical key performance indicators. Using technology to improve productivity, automate routine tasks, streamline workflow, and reduce turnaround time across clinical operations will be essential. Innovating processes and using technology to enhance evidence-based clinical care will also be part of your responsibilities. Developing and implementing quality improvement initiatives to enhance patient outcomes and satisfaction, achieving and maintaining accreditation from relevant regulatory bodies, and fostering a culture of continuous improvement are key components of the role. Managing budgets for medical services, including developing annual operating budgets, monitoring performance, identifying variances, and ensuring compliance with budgetary guidelines and financial regulations, will also be part of your responsibilities.,

The company Asian Hires based in Vadodara, Gujarat, India is offering a non-clinical job opportunity in a US-based MNC. The annual budget for freshers is 6,20,000 PA, while experienced candidates can earn up to 8,50,000 PA. As a Medical Officer at Asian Hires, your primary role will involve reviewing and verifying large volumes of patient's complete medical records with precision. You will be responsible for performing clinical reviews as per specific methodologies, preparing detailed reports including chronologies, timelines, summaries, mass tort matrix, and providing medical opinions on case validity and valuation. Your responsibilities will include analyzing and summarizing medical records for pre and post-settlement projects, interpreting clinical data using medical terminology, and ensuring adherence to company policies and principles to maintain the organizational culture. It is essential to comply with the Health Insurance Portability and Accountability Act (HIPPA) at all times and provide daily reports to the Medical Team Lead regarding productivity and quality. Candidates with an MBBS qualification are welcome to apply, without the need for prior experience. BHMS and BAMS graduates with at least 2 years of claim process experience in any insurance sector are also eligible. The ideal candidate should possess a basic knowledge of healthcare data analysis, clinical review, medical terminology, assessments, patient evaluation, and clinical medicine. Proficiency in using Microsoft Word, Adobe, and Excel is required. Preferred skills include familiarity with HIPPA regulations, critical thinking abilities, a basic understanding of US culture, and organizational culture and behavior. Asian Hires is an equal opportunity employer committed to diversity and inclusivity.,

The primary responsibility of this role is to manage Regulatory Affairs in compliance with relevant regulations and guidelines for the organization. As a Regulatory Affairs Manager at DDReg, you will be involved in reviewing clinical, biopharmaceutical, non-clinical, and labelling documentation. Your duties will include preparing and reviewing non-CMC sections, Variations, site transfers, and conducting post-approval gap analysis. Additionally, you will support the regulatory function through document management, electronic submission compilation, and other group management activities as needed. Collaboration with various departments such as Regulatory Affairs, Quality Assurance, Quality Control, Manufacturing, and Research and Development will be necessary to ensure regulatory compliance and operational excellence. Your responsibilities will involve providing high-quality reviews of CTD sections for regulatory filings to various regulatory authorities such as EMA, UK MHRA, National Agencies of EU Member states, Canada, Australia, and other markets globally. You will actively contribute to developing and implementing regulatory strategies, processes, and timelines for global approval. Conducting Gap Analysis of Non-CMC sections, authoring and compiling CTDs sections, preparing labelling documentation, managing labelling changes, and ensuring compliance with regulatory guidelines will be key aspects of your role. Furthermore, you will be required to demonstrate expertise in regulatory matters, collaborate with internal and external stakeholders, and provide technical consultation and advice on strategy and industry best practices. To excel in this role, you should possess a Bachelor's or Master's degree in Pharma and have at least 5+ years of relevant experience in the pharmaceutical/CRO industry. Strong project management skills, excellent interpersonal and communication skills, and in-depth knowledge of global regulatory guidelines are essential for success. Proficiency in Microsoft Word, PowerPoint, and Excel, along with the ability to work effectively in a team-oriented environment, are also crucial requirements. The ideal candidate should be adaptable, capable of working under pressure, and able to deliver high-quality results within tight timelines. This position is based in Gurgaon, Haryana, India. Occasionally, you may be required to work across different time zones to fulfill job requirements.,

The role of the Medical Officer based in Vadodara, India involves reviewing and verifying large volumes of patient's full medical records with precision. You will be responsible for performing clinical reviews as per specific methodologies and preparing detailed reports including chronologies, timelines, summaries, mass tort matrix, and medical opinions on case validity and valuation. Your key responsibilities will include analyzing and summarizing medical records for pre and post-settlement projects, interpreting clinical data using medical terminology and diagnosis, and adhering to company policies and ARCHER principles to maintain the Archer culture. It is essential to comply with the Health Insurance Portability and Accountability Act (HIPPA) at all times and provide daily reports to the Medical Team Lead on productivity and quality. In terms of technical skills, you should have a basic understanding of healthcare data analysis and clinical review, sound knowledge of medical terminology, assessments, patient evaluation, and clinical medicine. Proficiency in using Microsoft Word, Adobe, and Excel is required. Interpersonally, you should be able to work effectively in a team environment with staff at all levels to achieve business goals. The ability to perform under pressure, meet deadline-oriented project demands, manage multiple initiatives, and demonstrate effective communication skills are also crucial. Being detail-oriented, organized, and a motivated self-starter is essential for success in this role. No prior experience is required for this position. A degree in MBBS is necessary. Additional skills such as knowledge of HIPPA regulations, critical thinking, basic understanding of US culture, and organization culture and behavior will be beneficial. This is a permanent position within the operations department, reporting to the Medical Team Lead.,

As a Nurse Practitioner in the BPO (Healthcare) industry located at Infopark, Kakkanad, Kochi, you are required to have a minimum of 2 years of clinical experience. The role entails working the Night Shift from 6PM to 3AM with a monthly salary ranging from 30,000/- to 40,000/-. Fluency in English is a necessity for effective communication. Your responsibilities will include providing a comprehensive clinical review of complaints and appeals from providers, ensuring cost-effective delivery of health services by adhering to appropriate resources and guidelines. You will support the identification and review of suitable case types as per clinical guidelines, promoting quality effectiveness of Healthcare Services. It is crucial to accurately apply review requirements to guarantee that cases are reviewed by practitioners with the relevant clinical expertise. Additionally, the role requires the ability to interpret clinical laboratory results, be familiar with clinical conditions, and their management. The qualifications needed for this position include a Bachelor of Science in Nursing and a minimum of 18 months of clinical experience. Fluency in English is also a mandatory requirement. The willingness to work in shifts, particularly the Night Shift from 6PM to 3AM, is essential. The benefits provided for this role include Cab (pickup & Drop), Employee Stock Ownership, Provident Fund, Health Insurance, and a basket of allowances. This is a Full-time, Permanent position. Furthermore, additional benefits encompass Commuter assistance, Life insurance, and Yearly bonuses. The work schedule involves Fixed shifts from Monday to Friday, including Night and US shifts with Weekend availability. Shift allowances are provided along with other benefits. The educational requirement for this role is a Bachelor's degree, with a minimum of 2 years of experience in Clinical Nursing. A BSc Nurse license/certification is also mandatory. Night Shift availability is a requirement for this position, and the work location is in person.,

Roles and Responsibilities Entering of patient demogrpahics and insruance information. Verifying Insurance Policy coverage from the webportal. Order Corrections for the screnrios : Changes in the calories, different product, Hospital Re-admit, discharge, patient expired. Delivery Worksheet : Orders are being picked from the Patient Medical records Monthly facility billing (PART A Report ) and MA reports are prepared and sent to the client. Develop understanding of client specifics and requirements File are split and renamed as per the client naming convention. Renamed Invoices are allocated to the users for further tasks Based on the Invoice, users should reconcile or enter the PO in the accounting application. Following up with clients on Invoice clarification Understand special situations and procedures that relate to the client we work on. Performs other duties as assigned. Desired Candidate Profile Education, Training, and Experience Required: Bachelors Degree or 3 year Diploma or equivalent is required. Medical Transcription experience is a huge plus Two (2) years of Medical Billing DME Billing, Charge Entry, Payment Entry experience is preferred; Equivalent combination of experience, education, and training that would provide the required knowledge and abilities. Knowledge/Skills: Knowledge of medical terminology; anatomy and ; English grammar and usage. Ability to research and analyze data, draw conclusions, and resolve issues; read, interpret, and apply policies, procedures, laws, and regulations. Ability to read and interpret medical billing clinical notes Ability to develop training materials, make group presentations, and to train staff Ability to exercise independent judgment; Excellent written and verbal communication skills to prepare reports and related documents and to maintain working relationships with physicians and other staff. Ability to competently use Microsoft Office Suite, particularly Word, Excel and Outlook. Ability to maintain confidentiality. Perks and Benefits As per market standards

Position Reports To : Medical Team Lead Department : Operations Position Summary : - The role will be to review and verify large volumes of patient's full medical records with precision, perform clinical reviews as defined by the specific review methodologies and prepare a detailed report that includes chronologies and timelines, summaries, mass tort matrix and medical opinions on case validity and valuation. Job Responsibilities : - Analyzing and summarizing medical records for pre and post settlement projects. Interpreting clinical data in terms of medical terminology and diagnosis. o Adhering to company policies/ARCHER principles and hence taking good care of Archer culture. Adhere to Health Insurance Portability and Accountability Act (HIPPA) all the time. Daily reporting to Medical team lead for productivity & quality Knowledge, Skills And Abilities : - Technical Skills: Knowledge of basic level of health care data analysis and clinical review. o Sound knowledge of medical terminology, assessments, patient evaluation, and clinical medicine. Ability to work proficiently with Microsoft Word, Adobe, and Excel. Interpersonal Skills: Ability to perform well in a team environment, with staff at all levels, to achieve business goals. Ability to function under pressure and with deadline-oriented project demands as well as manage multiple initiatives. Team player and motivated self-starter. o Detail-oriented, organized, able to multi-task. Effective communication skills. Educational Qualification And Experience Required : - MBBS graduate (No experience required) BHMS/BAMS graduate (Minimum 2 years of experience with Claims Processing in the Insurance sector). Additional Skills : - HIPPA, Critical thinking, Basic understanding of US culture, Basic understanding of organization culture and behavior. Career Path : - Medical Officer Medical Team Lead