Clinical Review Specialist

hace 15 horas


San Cristóbal de las Casas, Chiapas, México Ibi Healthcare Institute A tiempo completo
Job Summary

We are seeking a highly skilled Clinical Review Specialist to join our team at IBI Healthcare Institute. As a Clinical Review Specialist, you will play a critical role in ensuring that preauthorization requests for medical procedures are thoroughly evaluated and processed in a timely manner.

Key Responsibilities:
  • Review and evaluate preauthorization requests for medical procedures to ensure compliance with established medical guidelines and protocols.
  • Collaborate with healthcare providers, physicians, and other stakeholders to obtain additional information or clarification as needed.
  • Conduct benefit reviews to determine insurance coverage for proposed medical procedures.
  • Communicate with insurance companies to obtain preauthorization approvals and address any denials or discrepancies.
  • Maintain accurate and detailed records of preauthorization requests, approvals, and denials.
  • Stay updated on changes in insurance policies, medical guidelines, and industry regulations affecting preauthorization processes.
  • Provide guidance and education to healthcare providers and staff on preauthorization requirements and best practices.
  • Work closely with billing and coding teams to ensure accurate and timely processing of preauthorized procedures.
  • Participate in continuous quality improvement initiatives to enhance the efficiency and effectiveness of the preauthorization process.
Qualifications and Requirements:
  • Clinical background, preferably with a degree in nursing or a related field.
  • Proven experience in a preauthorization or utilization review role, specifically within a large surgical center.
  • In-depth knowledge of medical procedures, terminology, and documentation requirements.
  • Familiarity with insurance benefit reviews and the preauthorization process.
  • Strong communication and interpersonal skills to effectively collaborate with healthcare providers, insurance companies, and internal teams.
  • Detail-oriented with excellent organizational and time-management skills.
  • Ability to work independently and make informed decisions in a fast-paced environment.
  • Proficient computer skills, including experience with electronic health records (EHR) and preauthorization software.
  • Knowledge of relevant healthcare regulations and compliance standards.
About IBI Healthcare Institute

Our mission is to provide high-quality, accessible, and affordable surgical care solutions. We are a surgical group devoted to providing the highest quality healthcare services. Our vision is to become the most respected and successful surgical group in the United States for our patients, members, and partners.



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