Job Description
Are you passionate about using your clinical expertise to support quality healthcare outcomes and ensure members receive medically appropriate services? Do you enjoy critically reviewing clinical documentation, applying evidence-based criteria, and collaborating with interdisciplinary teams to make informed medical necessity determinations? We're are recruiting for 2 full-time remote/hybrid Clinical Reviewer positions. This position is currently remote but may have minimal travel requirements to the DC office in the future. Candidates must reside in DC, Maryland or Virginia and a commutable distance to DC. The Clinical Reviewer position supports utilization management activities by assessing the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective reviews. This role reviews clinical documentation, applies clinical review criteria and organizational policies, documents review findings, communicates determinations, collaborates with internal teams and Medical Affairs, and supports quality and compliance standards throughout the review process. We’re looking for someone with strong critical thinking skills, attention to detail, and the ability to communicate clinical findings clearly and accurately in writing. If you are self-driven, adaptable, technologically proficient, and comfortable working independently in a fast-paced review environment, we encourage you to apply. Why Comagine Health? Comagine Health is a national, mission-driven, nonprofit organization that has engaged in health care quality consulting and quality improvement services for more than 50 years. We are leaders in assisting front-line providers and engaging health care partners to improve care delivery and patient outcomes. Our talented remote workforce spans the country and plays a vital role in our success. We go beyond merely providing a remote work option; we support and embrace it. We offer opportunities to make a difference from anywhere in the U.S. and enjoy better work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs. Benefits We believe in an environment that allows you to thrive both personally and professionally. That’s why we offer benefits that include: Medical, dental and vision insurance Paid time off for vacation, illness and volunteering Retirement savings plan with employer contribution Adoption financial assistance Paid parental leave And much more! You Have Associates in a related field 3 years of clinical (direct patient care) experience Current, active, unrestricted RN licensure for the District of Columbia You May Have 2 years of utilization review (or other medical management experience) preferred 2 years of fulltime substance use disorder and or behavioral health disorder experience preferred 1 year of utilization review (or other medical management experience) You Bring Strong MS Office Suite proficiency and familiarity with database software programs Strong organizational skills Excellent oral and written communications skills Excellent interpersonal and problem-solving skills Ability to organize and coordinate multiple simultaneous tasks in a team environment Computer skills, InterQual, ASAM, Milliman criteria experience preferred In This Role, You Will Apply clinical review criteria, organizational policies, 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 clinicians, when indicated. Provide daily oversight and monitoring of non-clinical staff during their performance of non-clinical support activities, as appropriate; also provide the supervisor with input regarding employees’ performance of these activities. Perform quality assurance audits and other program support, as assigned by supervisor. 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. Review and understand treatment plans to substantiate clinical appropriateness of services to ensure quality outcomes in support of medical necessity. Screen selected progress notes and other pertinent health care records to determine appropriateness for admission; perform initial and continued stay reviews using ASAM, InterQual and or other organization policy guideline