HCA, Hospital Corporation of America Clinical Reviewer in Santa Ana, California



  • Performs TAR reviews and completion of TAR requests according to Medi Cal format and deadlines

  • Performs Medi Cal clinical medical file review of hospital documentation for necessary clinical treatment and patient severity of illness to warrant admissions and continued acute inpatient level of care

  • Performs on line documentation of clinical justification for hospital stays and pre screening of files to determine if Appeal is warranted.

  • Documents clinical justification for Appeal requests

  • Conducts clinical review of cases that do not meet criteria

  • Performs clinical intake and reviews cases according to the policies and procedures of TOG.

  • Collects and enters confidential information ensuring the highest level of confidentiality in all areas.

  • Maintains written documentation according to TOG’S documentation policy

  • Provides ongoing to TAR related to TOG’s Clinical Review process Assists in the orientation and training of new clinical TAR staff in department.

  • Participates and understands scope of responsibility in all ongoing of the TAR Process.

  • Knowledge of care management plans and services in order to implement that knowledge in a clinical in-patient setting.

  • Knowledge of care management plans and services in order to implement that knowledge in a clinical setting.

  • Ability to use independent judgment related to medical record review.

  • Preferred RN from an accredited school of nursing

  • Preferred Current, active California RN license

  • 2-3 years experience in acute care environment

  • 3 years previous utilization management experience in a managed care and/or hospital setting

  • Computer proficiency

  • An associate or bachelor's degree in nursing or a hospital-sponsored diploma

  • Program.

  • Knowledge and proficiency of established clinical standards and guidelines with Medi-Cal

  • Good organizational skills preferred

  • Experience in both nurse review and assisting with the utilization review appeals process.

Title: Clinical Reviewer

Location: California-Santa Ana-Santa Ana (SAN) - RCPS

Requisition ID: 26576-120930