What does a clinical reviewer do?

1 Role of a clinical reviewer

A clinical reviewer works for various organizations, such as health insurance companies, hospitals, clinics, government agencies, or consulting firms. Their main goal is to ensure that the health care services provided to patients are consistent with the best available evidence, standards, and guidelines. They also help to reduce the costs and risks of unnecessary, inappropriate, or harmful interventions. A clinical reviewer may review individual cases, such as claims, appeals, or complaints, or conduct systematic reviews of policies, programs, or practices.

2 Responsibilities of a clinical reviewer

Clinical reviewers have a range of responsibilities depending on the type and scope of their review, such as reviewing medical records and applying clinical criteria to assess the quality of care. It is also important to identify and report any discrepancies, errors, fraud, abuse, or quality issues that may affect the patient's health outcomes or the organization's performance. Additionally, clinical reviewers must communicate with health care providers, patients, or other stakeholders to obtain additional information and provide feedback or recommendations. Furthermore, they must document and report their findings in a clear, concise, and timely manner while staying up-to-date with the latest clinical evidence, standards, and regulations that may affect the review process or the health care sector.

3 Skills of a clinical reviewer

A clinical reviewer must possess a combination of clinical knowledge, analytical skills, and interpersonal skills in order to effectively carry out their duties. For instance, they must have a thorough understanding of medical terminology, anatomy, physiology, pathology, pharmacology, and treatment options related to their specialty or field of review. Additionally, they must be able to collect and interpret data from various sources while applying critical thinking and problem-solving skills. Furthermore, the ability to communicate effectively with different audiences is essential for a clinical reviewer. They must also be able to work collaboratively with other reviewers or team members while handling sensitive or confidential information with respect and discretion.

4 Qualifications of a clinical reviewer

A clinical reviewer usually needs to have a minimum of a bachelor's degree in a health-related field, such as nursing, medicine, pharmacy, or allied health. Some employers may also require a master's degree, a certification, or a license in a specific specialty or area of review. Additionally, a clinical reviewer may need to have some relevant work experience in a clinical setting, such as a hospital, a clinic, or a health care facility. Depending on the employer, a clinical reviewer may also need to have some knowledge or skills in areas such as health informatics, quality improvement, or project management.