Clinical Evaluator

About the role

The Clinical Evaluator is responsible for completing timely and accurate patient pre-admission screenings (PAS), PAS updates, and ensuring CMS-13 compliance for patients referred for inpatient rehabilitation services. This position collaborates with the Business Development team, including Clinical Liaisons, the Admissions Coordinator, Admissions staff, physicians, nursing, case management, therapy, and other stakeholders to facilitate the referral-to-admission process efficiently. The Clinical Evaluator serves as a clinical resource while supporting regulatory compliance, payer requirements, and exceptional patient care.

Responsibilities

• Complete comprehensive pre-admission screenings (PAS) and PAS updates accurately and within established turnaround times (goal of two hours).
• Evaluate referred patients to determine medical necessity, rehabilitation potential, and appropriateness for inpatient rehabilitation admission.
• Review medical records, therapy evaluations, physician documentation, laboratory results, and clinical information to ensure patients meet rehabilitation admission criteria.
• Ensure all documentation complies with CMS-13 requirements, Medicare regulations, hospital policies, and payer guidelines.
• Collect, document, analyze, and communicate clinical information supporting admission decisions.
• Review referrals to identify insurance requirements, pre-certification needs, financial coverage, and admission criteria.
• Serve as the clinical liaison with the Admissions Office and insurance companies by providing clinical documentation necessary to obtain pre-certifications and prior authorizations.
• Monitor pending referrals and proactively follow up on internal and external issues affecting referral and admission timelines.
• Maintain accurate documentation within the electronic medical record and other required systems.
• Develop and maintain strong working relationships with physicians, referral sources, hospitals, case managers, discharge planners, Clinical Liaisons, Admissions staff, and hospital leadership.
• Maintain open communication with the Director of Business Development, Clinical Liaisons, Admissions, nursing, and interdisciplinary team members to promote teamwork and cooperation.
• Serve as a clinical resource regarding rehabilitation admission criteria, payer requirements, and referral appropriateness.
• Deliver exceptional customer service while fostering positive relationships with patients, families, and referral partners.
• Maintain knowledge of PPS payment and reimbursement systems, DRGs, case weights, Medicare regulations, and current inpatient rehabilitation admission requirements.
• Achieve established individual productivity and performance goals.
• Participate in quality improvement initiatives, departmental meetings, and ongoing education as assigned.
• Maintain HIPAA compliance and protect patient confidentiality at all times.
• Perform additional duties and special projects as assigned.

Requirements

• Clinical degree in a healthcare-related field whose education and scope of practice support competent assessment of medical conditions, functional status, rehabilitation potential, and risk for medical and functional complications.
• Current unrestricted licensure in Nursing (RN), Medical Social Work (LMSW/LCSW), or Therapy (OT, PT, RT, or SLP) is required.
• Minimum of two (2) years of Clinical Liaison experience preferred; prior Inpatient Rehabilitation Facility (IRF), LTACH, acute care, or case management experience preferred.
• Excellent clinical assessment and critical thinking skills.
• Excellent written, verbal, and interpersonal communication skills.
• Ability to collect, document, analyze, and communicate clinical information accurately.
• Strong relationship management skills with physicians, referral sources, patients, families, and interdisciplinary team members.
• Knowledge of PPS payment and reimbursement systems, DRGs, case weights, CMS regulations, and payer authorization processes preferred.
• Ability to prioritize multiple referrals while meeting established turnaround times.
• Proficiency with Microsoft Office applications, electronic medical record (EMR) systems, word processing, and data entry.
• Ability to multitask and effectively interact with internal and external customers.
• Ability to communicate effectively in English by phone, in writing, and in person with staff, patients, families, physicians, and referral partners.

Benefits

• Medical Insurance
• Dental Insurance
• Vision Insurance
• Company-Paid Life Insurance
• 401(k) Retirement Savings
• Supplemental Voluntary Benefits
• Paid Time Off with Cash-Out and Donation Options
• Paid Holidays
• Pay on Demand (Payday Advance)
• Gym Membership and Fitness Program Discounts
• Employee Discounts on Everyday Purchases and Services
• Access to Automobile and Home Insurance Marketplace
• And More!