Clinical Reviewer Lead
About Company: 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. 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! Comagine Health actively cultivates an organizational culture that fosters well-being and prioritizes engagement, connectedness and collaboration among team members. Each employee’s unique background, perspective and abilities are fundamental to the success of our mission and organization. Comagine Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability. We are proud to be a Recovery Friendly Workplace, supporting the health and well-being of all employees. About the Role: Lead Clinical Reviewer DC Medicaid Contract The Clinical Review Lead is responsible for designing, implementing, and evaluating reviews by coordinating, delegating, and supporting the Clinical Review team This position serves as a subject matter expert for FFS reviews, as well as Long Term Care reviews for the DC Contract The Clinical Reviewer Lead plays a pivotal role in overseeing the clinical review process to ensure the highest standards of quality and compliance within healthcare services. This position is responsible for leading a team of clinical reviewers, providing expert guidance and support to ensure accurate and timely evaluation of medical records and claims. The role requires collaboration with cross-functional teams to develop and implement review protocols that align with regulatory requirements and organizational goals. The Clinical Reviewer Lead will analyze complex clinical data to identify trends, improve processes, and support decision-making that enhances patient care outcomes. Ultimately, this role ensures that clinical reviews are conducted with integrity, accuracy, and efficiency, contributing to the overall success of healthcare service delivery in the Washington DC area. Minimum Qualifications: Bachelor’s degree in Nursing, Health Sciences, or a related clinical field. Active RN licensure. Minimum of 5 years of clinical review experience within healthcare services. Strong knowledge of medical terminology, clinical documentation, and healthcare regulations. Proven leadership experience managing clinical teams or projects. Excellent analytical, communication, and organizational skills. Preferred Qualifications: Master’s degree in Nursing, Healthcare Administration, or a related discipline. Certification in Clinical Documentation Improvement (CDI) or Certified Professional Medical Auditor (CPMA). Experience with electronic health record (EHR) systems and clinical review software. Familiarity with Medicare, Medicaid, and other payer regulations. Experience working in a fast-paced healthcare environment with multidisciplinary teams. Responsibilities: Lead and mentor a team of clinical reviewers, providing training, performance feedback, and professional development opportunities. Conduct and oversee detailed clinical reviews of medical records, claims, and related documentation to ensure accuracy and compliance with established guidelines. Collaborate with healthcare providers, auditors, and internal departments to resolve discrepancies and improve review processes. Develop, update, and implement clinical review protocols and quality assurance measures to maintain regulatory compliance and enhance review effectiveness. Analyze clinical data and review outcomes to identify trends, recommend improvements, and support strategic decision-making. Skills: The Clinical Reviewer Lead utilizes strong clinical knowledge and analytical skills daily to assess complex medical records and ensure compliance with healthcare standards. Leadership and communication skills are essential for effectively managing and motivating the clinical review team, as well as collaborating with various stakeholders. Attention to detail and critical thinking are applied to identify discrepancies and recommend process improvements. Familiarity with healthcare regulations and documentation standards guides the development and enforcement of review protocols. Additionally, proficiency with clinical software and data analysis tools supports efficient review workflows and informed decision-making.