Clinical Review Resume Sample

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Eden Watsica
5108 Rowland Rapid,  Dallas, TX
+1 (555) 405 7121

Work Experience

Clinical Review Specialist
05/2015 - PRESENT
San Francisco, CA
  • Reads and understands project protocols and Data Validation Manuals
  • Identifies data issues and works with PPD team and study sites to resolve
  • Ensures applicable data review activities are conducted accurately, and all related deliverables are completed to quality expectations, within budget and on time
  • Provides support, guidance and direction on clinical data review to the CDM project team
  • Normally receives general instructions on routine work, detailed instructions on new projects or assignments. Exercises judgment within defined procedures and practices to determine appropriate action
  • Contacts are primarily internal to the company with infrequent external customer / vendor contact on routine matters. Builds productive internal / external working relationships
  • Supports and educates patients in areas including but not limited to: medication management and adherence; exercise; nutrition; health care system navigation
  • Provides support and notifies clinical team and manager regarding changes in: Behavior, nutrition, exercise, substance use, medication compliance, and other issues as related to the established care plans
  • Help and coordinate patient transportation and accompaniment as needed, to scheduled appointments
Clinical Review Analyst
09/2010 - 02/2015
Los Angeles, CA
  • Consistently meet Level 1 productivity requirements (10+ authorizations per hour after 6 months)
  • Perform clinical validation of inpatient claims in a timely manner
  • Perform appeal reviews and respond to provider disputes for Clinical Validation Audits
  • Assist with DRG coding appeal reviews as requested by clients or providers
  • Screen claims data
  • Interface with Physician advisors, coders, and other members of the audit team
  • Maintain current knowledge of clinical guidelines and client expectations
  • Communicate audit findings and appeal responses with excellent writing skills
  • Demonstrate commitment to Change Healthcare core values
Clinical Review Assistant
02/2007 - 06/2010
San Francisco, CA
  • Participate in all regular required documentation for regulatory standards
  • Maintains written documentation according to TOG’S documentation policy
  • Provides ongoing to TAR related to TOG’s Clinical Review process
  • Participates and understands scope of responsibility in all ongoing of the TAR Process
  • Support and educate patients in areas including but not limited to: medication management and adherence; exercise; nutrition; health care system navigation. (Within the scope of certification/licensure)
  • Assist patients and coordinate with the care coordinators and the clinics regarding patient needs such as transportation, arrangements of appointments, medications, etc
  • Complete all required documentation for regulatory standards


University of Mount Union
2002 - 2006
Bachelor's Degree in Health

Professional Skills

  • Experience that demonstrates strong attention to detail and skill with numbers Strong command of English language and grammar
  • Organizational skills and prioritization skills
  • Excellent interpersonal skills and experience interacting with clinicians and financial personnel
  • Good negotiation skills to effectively negotiate fees with providers, hospitals and extended care facilities
  • Experience reviewing and validating medical data
  • Experience in managed care contracts, reconciling patient accounts, and balancing payment transactions against contract rates and terms is strongly desired
  • Excellent understanding of pharmaceutical/clinical/medical terminology

How to write Clinical Review Resume

Clinical Review role is responsible for basic, mainframe, database, auditing, reporting, research, insurance, health, microsoft, transportation.
To write great resume for clinical review job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Clinical Review Resume

The section contact information is important in your clinical review resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Clinical Review Resume

The section work experience is an essential part of your clinical review resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous clinical review responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular clinical review position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Clinical Review resume experience can include:

  • Proven success managing, implementing or auditing quality programs
  • Clinical practice experience
  • Health insurance/managed care experience
  • Previous utilization management experience in a managed care
  • Skilled in interactive computer programs
  • Ten years of experience in a complex health care environment

Education on a Clinical Review Resume

Make sure to make education a priority on your clinical review resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your clinical review experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school

These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Clinical Review Resume

When listing skills on your clinical review resume, remember always to be honest about your level of ability. Include the Skills section after experience.

Present the most important skills in your resume, there's a list of typical clinical review skills:

  • Communicate effectively and document the biopsychosocial basis for triage, referral and authorization decisions
  • Communicate effectively selection factors related to a broad range of behavioral health care intervention modalities
  • Effectively utilize community resources in the care of individuals with mental or substance use disorders
  • Attain and maintain a working knowledge of Good Clinical Practices and applicable Standard Operating Procedures
  • Organize and prioritize work, and meet critical deadlines
  • Prepare clear, accurate and effective reports, correspondence and other written materials

List of Typical Skills For a Clinical Review Resume


Skills For Clinical Review Specialist Resume

  • Experience in a clinical research environment
  • Managerial/supervisory experience
  • Healthcare/Health Plan experience
  • Reviewing service denials by both government and commercial payers
  • Preparing appeal letters for reconsideration of appropriate medical care based on documentation
  • Document reviews, issues pertaining to quality of care, and clinical appeals

Skills For Manager of Clinical Review Resume

  • Evaluate cases and perform advanced differential diagnosis of a mental disorder
  • Evaluate cases and perform advanced clinical risk assessment
  • Input and/or access data via system-wide network computers and personal computers
  • Interpret, explain and apply complex regulations, policies and procedures
  • Assessing inpatient admission criteria and length of stay, as well as outpatient medical necessity requirements by payer for specific tests, examinations, medication administration, therapeutic and diagnostic procedures or services
  • Applysmedical criteria and patient specific presenting illness, injury, clinical condition, symptom and/or complaint for obtaining payer prior approval, pre-authorization or authorization for ordered services, and assisting with clinical documentation improvement training
  • Social and behavioral aspects of mental, emotional, substance use disorder (SUD)-related disturbances and their characteristics
  • Scope, activities and functions of the various behavioral health facilities and public and private community agencies providing services to mental health and substance use disorder clients
  • Policies, procedures, and systems related to Behavioral Health Care Services, legal and regulatory requirements and limitations

Skills For Clinical Review Analyst Resume

  • Applicable federal, state and local laws, rules and regulations
  • Act as leader for Quality Management clinical review processes
  • Identify, examine, and present significant findings to relevant parties
  • Pick up on patterns in order to implement strategies that optimize performance
  • Resourceful and adept at seeking or collecting and synthesizing informationfrom a variety of clients and sources in an objective, unbiased manner in order to reach a sound conclusion, goal, or judgment
  • Collaborative spirits eager to actively participate as a member of a team contributing successfully to the completion of goals and objectives aligned with the mission, vision and values of the Behavioral Health Care Services system of care
  • Well organized, capable of multi-tasking and planning daily work activities, and establishing a course of action for self and others to ensure that work is completed efficiently
  • An effective communicator who conveys information and ideas verbally and in writing in a manner that meets audience needs; and develops and maintains effective relationships with others by relating well to people with diverse cultures, interpersonal styles, abilities, motivations, or backgrounds

Skills For Clinical Review Senior Analyst Resume

  • An understanding of healthcare reimbursement practices and payer compliant claims preparation for both governmental and commercial payers. CCS, CPC, COC, CIS, National HIM certifications from the AAPC or AHIMA
  • Collaborative work experience with a hospital Revenue Cycle department desired
  • Exercise understanding of hospital and professional services payer adjudication rules
  • Read and interpret medical charts and related documentation
  • Experience in hospital operations and general understanding of revenue cycle with an emphasis on coverage, charge capture, coding, billing and reimbursement methodologies
  • Critical thinker with demonstrated ability to perform root cause analysis, problem solve, prepare and implement action plans and lead improvement initiatives

Skills For Clinical Review Operations Supervisor Resume

  • Clinical experience in critical care or med-surgical required
  • Performance - maintain performance standards that ensure the department is operating at peak proficiency and that established goals are consistently being met
  • Adapt to a changing and dynamic environment
  • Comfortable working in both individual and team settings, and on-site with clients
  • Communication - communicate clearly and concisely, verbally and in writing; utilize appropriate method/tool to communicate with other departments as necessary

Skills For Clinical Review Auditor Resume

  • Keen attention to detail with ability to spot trends and proactively reduce denials
  • Proficiency in the use of PCs and MS Office suite
  • Effectively apply knowledge and skills in a highly organized fashion utilizing adherence to regulatory guidelines, Standard Operating Procedures and client expectations
  • Experience that demonstrates strong attention to detail
  • Registered Nurse (RN) with unrestricted, current license in state of operations
  • Knowledge of accreditation standards/legislation, i.e. URAC, NCQA
  • Understands and files appropriate levels of appeal (ie: reconsideration, dispute, appeal, ALJ, etc.)

Skills For Clinical Review Assistant Resume

  • Perform hospital bill review including desk and on-site hospital bill auditing; provides recommendations on appropriate payment of medical bills and posts files to explain adjustments
  • Negotiate fees with providers, hospitals, and extended care facilities and maintains current database for new medical trends and unscheduled procedures along with specific jurisdictional fee schedules
  • Evaluating clinical documentation
  • Review incoming medical bills and/or analyzes product and general liability
  • Maintain current database including log of monthly activity on all reviewed cases from assignment to completion
  • Analyze medical records related to the case files referred and makes recommendations as to the compensability of medical care provided

Skills For Hedis Clinical Review Manager Resume

  • Provide assistance on medical arbitration
  • Prepare and submits dispute resolutions to appropriate state agencies
  • Evaluates, reports findings, and provides recommendations on denied or underpaid claims
  • At the direction of Xtend Project leaders and based on instructions provided by the client (hospital and/or physician practice) assists to ensure services inappropriately denied by payers are identified, compliantly appealed and reversed
  • Works closely with appropriate departments / functional areas of the client, e.g. Patient Care Management, HIM/coding and medical team, to review and obtain medical documentation required to facilitate denial appeals process

Skills For Associate Director, Hedis Clinical Review Resume

  • Continuously reviews applicable regulations, updates and maintains current knowledge
  • Professionals who would takepersonal satisfaction and pride representing the County and serving as part of a team directly responsible for either providing initial clinical screening and service referrals over the telephone in a fast-paced, high volume call center environment or providing quality assurance and utilization review of clinical resources
  • Practiced problem solvers capable of making well supported decisions by identifying and understanding issues, problems, and opportunities; comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action; and solving problems by taking action that is consistent with available facts, constraints, and probable consequences

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