Clinical Reviewer DC

COMAGINE HEALTH•Remote, US,

2d•Hybrid

About The Position

Comagine Health is seeking two full-time remote/hybrid Clinical Reviewer positions. This role supports utilization management by assessing the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective reviews. The Clinical Reviewer will review clinical documentation, apply clinical review criteria and organizational policies, document findings, communicate determinations, collaborate with internal teams and Medical Affairs, and support quality and compliance standards. Strong critical thinking, attention to detail, and clear written communication skills are essential. The ideal candidate is self-driven, adaptable, technologically proficient, and comfortable working independently in a fast-paced review environment. This position is currently remote but may require minimal travel to the DC office in the future. Candidates must reside in DC, Maryland, or Virginia and be within a commutable distance to DC.

Requirements

Associates in a related field
3 years of clinical (direct patient care) experience
Current, active, unrestricted RN licensure for the District of Columbia
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

Nice To Haves

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
InterQual, ASAM, Milliman criteria experience preferred

Responsibilities

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.
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 guidelines.
Review case files to ensure that patient’s level of care status is appropriate on admission and prior to discharge.
Communicate timeline with the Client, internal team or providers and provide relevant information as appropriate.
Document utilization review decision in the appropriate database.
Act as a resource for peers and or others (care management staff) regarding utilization review related questions and or review processes.
Assist with appeal case preparation for medical affairs and in accordance or departmental or organizational policies.
Report HIPPA or PHI violations timely into the appropriate organization database.
Provide clinical and/or review process subject matter expertise; respond to customer questions or concerns.
Perform other duties as assigned.