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Clinical Reviewer

Remote:

Full Remote

Experience:

Mid-level (2-5 years)

Work from:

United States

Offer summary

Qualifications:

Active RN license, Utilization review experience, 5+ years of clinical experience preferred, Familiar with InterQual criteria, Experience with Medicaid preferred.

Key responsabilities:

Apply clinical review criteria and screens
Consult with physicians when needed
Provide clinical expertise to clients
Conduct quality assurance audits and support
Report HIPAA violations in database

Comagine Health

201 - 500 Employees

See more Comagine Health offers

Job description

Category

Care Management

Job Location

Remote

Tracking Code

134732

Industry

Health Care

Job Level

Mid Career

Position Type

Full-Time/Regular

Years of Experience

5+ to 7 Years

Who is Comagine Health?

Comagine Health is a national, nonprofit, health care consulting firm. We work collaboratively with patients, providers, payers, and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system.

As a trusted, neutral party, we work in our communities to address key, complex health, and health care delivery problems. In all our engagements and initiatives, we draw upon our expertise in quality improvement, care management, health information technology, analytics, and research.

We invite our partners and communities to work with us to improve health and redesign the health care delivery system.

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!

Required Experience and certifications - licensure:

Must have an active RN license.
Utilization review experience required.
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

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.