Clinical Review Specialist

The Kestra team has over 400 years of experience in the external and internal cardiac medical device markets. The company was founded in 2014 by industry leaders inspired by the opportunity to unite modern wearable technologies with proven device therapies. Kestra’s solutions combine high quality and technical performance with a wearable design that provides the greatest regard for patient comfort and dignity. Innovating versatile new ways to deliver care, Kestra is helping patients and their care teams harmoniously monitor, manage, and protect life.

The Clinical Review Specialist (CRS) is responsible for reviewing physician treatment orders and interpretation of medical records and clinical documentation to help ensure information submitted to health insurance companies meet their published criteria for approval treatment by Durable Medical Equipment (DME). Ensure that details of the patient's condition, physician orders, course of treatment are well supported by clinical documents accompanying the prescription Order Packet. Ability to understand and analyze health insurance plan language documentation and utilize pre-approved criteria/guidelines and insurance plan language to validate necessity/appropriateness of treatment (i.e. Medical Policy Plan Language).

ESSENTIAL DUTIES:

• Review different types of clinical documentation including, but not limited to, medical records, EOBs, appeal letters, and denial/approval letters
• Ensure that details of the patient's condition, physician orders, course of treatment and well supported rationale are present within the clinical reviewer’s final review
• Review and interpret medical records to appeal denied insurance and Medicare claims
• Apply clinical judgement and knowledge for level of care and medical necessity reviews. Will assist with the submission of Prior Authorizations to health insurance companies
• Draft Appeals for PA Denied due to Medical Reasonableness and Necessity
• Confirm that the correct template (medical argument) is used
• Confirm letter is well written and logically structured
• Confirm all attachments are listed properly and included with appeal letter
• Verify that the number of pages coincide with what is scanned to the server
• Perform various computer functions including saving, copying, pasting, scrolling, etc.
• Liaison with legal and regulatory departments regarding training materials processes
• Participate in on-call and off hours coverage. Hours on-call and worked may include evenings, weekends, and holidays
• Adhere to Pledge of Confidentiality
• Information regarding a patient of this company shall not be released to any source outside of this company without the signed permission of the patient. Furthermore, information will only be released internally on a need-to-know basis. All Team Members will not discuss patient cases outside the office or with anyone not employed by this company unless they are directly involved with the patient’s case

COMPETENCIES:

• Passion: Contagious excitement about the company – sense of urgency. Commitment to continuous improvement.
• Integrity: Commitment, accountability, and dedication to the highest ethical standards.
• Collaboration/Teamwork: Inclusion of Team Members regardless of geography, position, and product or service.
• Action/Results: High energy, decisive planning, timely execution.
• Innovation: Generation of new ideas from original thinking.
• Customer Focus: Exceed customer expectations, quality of products, and experience always present of mind.
• Emotional Intelligence: Recognizes, understands, manages one’s own emotions and is able to influence others. A critical skill for pressure situations.
• Passionate about the heart-failure space and a strong desire to make a difference.
• Has a deep passion for solving problems of healthcare with enthusiasm for building positive working relationships and winning as a team.
• Ability to analyze clinical documentation in relation to utilization reviews.
• Ability to interpret and apply appropriate guidelines to utilization reviews.
• Ability to understand and contribute to commercial goals.
• Enjoys taking complex processes and breaking them down into simple and repeatable processes

Education/Experience Required:

• Bachelor’s degree
• 2+ years of experience in electrophysiology, cardiology, nursing, and/or medical device field
• Licensed as a Registered Nurse, Nurse Practitioner, Physicians Assistant, Medical Assistant, or other healthcare delivery credentials
• Competency in Microsoft tools (Outlook, Excel, Teams)
• Experience in patient and/or clinical education
• Ability to consistently work remotely

Preferred:

• Knowledge of MS Office, Excel, PowerPoint, MS Teams
• Knowledge and experience evaluating diagnosis or clinical indications compared to Health Insurance Medical Policy and/or coverage criteria
• Experience with Salesforce
• Direct cardiac patient care experience – RN, RT, PA, NP, MA, CVIS, Paramedic, CRM
• Clear and simple communication style
• Highly organized, service and detail oriented
• Ability to work cross-functionally between different departments
• Strong interpersonal skills with communicating and assisting clinicians with providing care for patients
• High level of oral and written communication skills with a demonstrated ability to deliver excellent customer service

WORK ENVIRONMENT:

• Fast-paced, evolving workflow from your remote workstation
• Extended hours when needed
• Kestra manufactures and provides life-saving products regulated by the Federal Food and Drug Administration and under contract with Medicare. Kestra maintains a drug free workplace and testing is a condition of employment post-offer.

PHYSICAL DEMANDS:

• Frequent stationary position, often standing or sitting for prolonged periods of time
• Frequent computer use
• Frequent phone and other business machine use
• Occasional bending and stooping
• Ability to lift up to 10 pounds unassisted

TRAVEL:

• Occasional travel, less than 5%

OTHER DUTIES

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the Team Member. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice.

Kestra offers a very competitive benefit package including Medical, Dental, 401K with Match, etc.

Pay equity is an important part of Kestra’s Culture. Our compensation ranges are guided by national and local salary surveys and take into consideration experience level and internal equity. Each role is benchmarked based on the job description provided. If your qualifications and/or experience level are outside of the posted position, we encourage you to apply as we are growing fast and roles that are coming soon may not be posted.

Salary: Annualized between $85,000 - $95,000. Depending on experience and location.

Kestra Medical Technologies is an equal opportunity employer. Kestra Medical Technologies does not discriminate on the basis of race, color, religion, national origin, veteran status, disability, age, sexual orientation, gender identity and/or expression, marital status, or any other characteristic protected by law.

We are unable to sponsor or take over sponsorship of employment visas at this time. Applicants must be eligible to work for any employer in the U.S.

Kestra manufactures and provides life-saving products regulated by the Federal Food and Drug Administration and under contract with Medicare.  Kestra maintains a drug free workplace and testing is a condition of employment.