Medical Clinical Reviewer / Clinical Program Specialist | Managing Consultant

Guidehouse • Tysons Corner, VA

1d • Hybrid

About The Position

We are seeking experienced clinicians to support federal health programs by providing expertise in healthcare delivery, clinical documentation, utilization management, medical necessity review, clinical operations, and patient care pathways. In this role, you will help evaluate how healthcare services are delivered, documented, reviewed, and operationalized across complex healthcare environments. Working closely with coding, reimbursement, operational, and analytics stakeholders, you will apply your clinical expertise to assess treatment pathways, care delivery patterns, documentation requirements, service relationships, and healthcare utilization to support consistent program decision-making and operational implementation. The ideal candidate brings experience in one or more areas including clinical practice, utilization management, prior authorization, medical review, clinical documentation improvement, case management, payment integrity, or healthcare operations. This individual should be comfortable evaluating healthcare services from both a clinical and operational perspective and translating healthcare delivery requirements into practical recommendations that support program objectives, stakeholder decision-making, and scalable healthcare processes.

Requirements

• Active clinical licensure as a Registered Nurse (RN), Nurse Practitioner (NP), Physician Assistant (PA), Physical Therapist (PT), Occupational Therapist (OT), or equivalent clinical credential.
• 5+ years of experience in one or more of the following areas: clinical practice, utilization management, prior authorization, medical review, clinical documentation improvement, payment integrity, case management, provider operations, or healthcare program operations.
• Experience reviewing medical records, clinical documentation, treatment plans, or healthcare services to support clinical and operational decision-making.
• Strong understanding of patient care pathways, healthcare service utilization, treatment progression, and standards of care.
• Experience working within payer, provider, Medicare, Medicaid, TRICARE, VA, commercial, or federal healthcare environments.
• Ability to communicate complex clinical concepts to operational, technical, and non-clinical stakeholders.

Nice To Haves

• Experience supporting large-scale federal health, payer, or provider programs with complex clinical, operational, or policy requirements.
• Experience translating clinical review findings into practical business rules, audit concepts, decision frameworks, or operational guidance.
• Experience working with claims, authorization, encounter, or utilization data to inform clinical review or program decisions.
• Experience supporting governance, validation, quality review, or implementation activities for healthcare programs or payment integrity initiatives.

Responsibilities

• Evaluate healthcare services, procedures, and treatment activities for clinical appropriateness, medical necessity, and alignment to standards of care.
• Assess patient care pathways and treatment progression across a variety of clinical conditions and specialties.
• Review relationships among diagnoses, procedures, imaging, laboratory services, therapies, medications, supplies, and follow-up care.
• Assess clinical documentation requirements and documentation practices that support healthcare decision-making and service delivery.
• Identify gaps, inconsistencies, missing services, or additional clinical considerations that should be evaluated.
• Collaborate with coding, reimbursement, analytics, and operational stakeholders to evaluate healthcare service relationships and clinical considerations.
• Validate that proposed approaches align with real-world healthcare delivery, provider workflows, and patient care experiences.
• Support development of clinical rationale, inclusion criteria, exclusions, assumptions, and supporting documentation.
• Participate in stakeholder reviews, governance activities, quality control reviews, and validation processes.
• Document findings, recommendations, risks, and decision rationale to support implementation and ongoing program management.

Benefits

• Medical, Rx, Dental & Vision Insurance
• Personal and Family Sick Time & Company Paid Holidays
• Position may be eligible for a discretionary variable incentive bonus
• Parental Leave and Adoption Assistance
• 401(k) Retirement Plan
• Basic Life & Supplemental Life
• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
• Short-Term & Long-Term Disability
• Student Loan PayDown
• Tuition Reimbursement, Personal Development & Learning Opportunities
• Skills Development & Certifications
• Employee Referral Program
• Corporate Sponsored Events & Community Outreach
• Emergency Back-Up Childcare Program
• Mobility Stipend

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed