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Clinical Reviewer, Washington, DC

Organization: Comagine Health
Category: Professional
Location: Washington, DC
Date Job Posted: May 28, 2021
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Clinical Reviewer

Tracking Code


Job Description

Together with our partners, Comagine Health works to improve health and create a better health care system so that people and communities will flourish.

We offer a competitive pay and benefits package plus employment with Comagine Health qualifies if you apply for the Public Service Loan Forgiveness (PSLF) Program!

We are looking for a registered nurse to join our Care Management team with utilization review experience (critical care, acute in-patient hospital, LTAC, rehabilitation, behavioral health, home health and hospice).

What you’ll be doing for us:

  • Apply clinical review criteria, guidelines, and screens to determine the medical necessity of health care services.
  • Consult with physician/practitioner consultants when reviews fail clinical review criteria, guidelines, and screens.
  • Refer cases to other professionals internally, including medical affairs consultation, as well as to customers and other appropriate external sources when indicated.
  • Provide clinical and/or review process subject matter expertise; manage complex reviews, respond to customer requests or complaints; monitor and report pertinent observations of clinical performance.
  • Provide initial clinical orientation to new employees as well as ongoing clinical mentoring and support for clinical review staff.
  • Collaborate with the clients to provide clinical expertise on complex cases and or process clarification.
  • Collaborate with Medical Affairs for complex case review and clinical topics.
  • May perform quality assurance audits and program support as assigned.
  • Report HIPAA and or PHI violations in the appropriate Freshservice database
  • As appropriate, provide daily oversight and monitoring of non-clinical staff during their performance of non-clinical support activities; also provide the supervisor with input regarding employees’ performance of these activities.
  • Provide clinical and/or review process subject matter expertise; respond to customer questions or concerns.
  • May perform quality assurance audits and other program support, as assigned.

Required Skills

What would make you a strong fit for our role:

  • Computer skills, InterQual criteria experience
  • Two years + of experience and skills in work processing, familiar with database software programs ( Microsoft Office). Basis spread sheet and presentation software Applications.
  • Excellent oral and written communication skills
  • Excellent interpersonal and problem-solving skills
  • Excellent critical thinking skills and the ability to multitask
  • Ability to organize and coordinate multiple simultaneous tasks in a team environment.
  • Ability to conduct an assessment including identifying strengths and needs, life domain functionals, risk, cultural factors, behavioral and emotional needs; assess trauma and substance sue, health and safety risks to self or others, gathering histories of mental and physical health ,substance use, past mental health services, assessing care giver resources and needs, social and work relationships; community based person centered plan review experience, community based elderly persons with disability service experiences, nursing home quality chart review with Minimal Data Set ( MDS) skill set experience;
  • Experience with Medicaid preferred.
  • Provide overall clinical knowledge and expertise for assigned contracts, client topics and problem-solving challenging cases.
  • Lead clinical training initiatives for the team in collaboration, manager/supervisor and or Medical Affairs.
  • Provide clinical mentoring and support for UM clinical review process both for new employees and for ongoing support of all clinical staff.
  • Assess and assist other reviewers to assess the medical necessity and quality of healthcare services by conducting prospective, concurrent, and retrospective utilization management reviews.
  • Strong knowledge of Medicaid, insurance utilization and quality control
  • Familiarity with InterQual and or other clinical decision medical necessity support system/tool
  • Familiarity with at least one medical management application (e.g., Jiva) preferred.

Required Experience

Required Experience:

  • BA / BS in nursing preferred as well as some experience in the field of case management and or utilization review; Equivalent combination of education and/or work experience may be substituted.
  • 5 + years of clinical (direct patient care) experience, critical care and or emergency room experience preferred.
  • 1+ years of utilization review (or other medical management experience) 3 years preferred.
  • 1 + years of mental health experience preferred.
  • 1 + years of experience in clinical record review/assessment and data entry
  • 1 + years of demonstrated experience working with infants, children, young adults, adults, and families

Job Location

Washington, District of Columbia, United States

Salary Type


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