Clinical Reviewer DC

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.

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 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.
• Refer cases to others, 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.
• Provide clinical and/or review process subject matter expertise; respond to customer questions or concerns.
• Perform quality assurance audits and other program support, as assigned.
• Perform other duties as assigned.

Physical Requirements & Work Environment

This position is primarily remote and performed in a home-based setting, requiring reliable internet access and a workspace free from significant distractions. The role involves frequent use of computers, phones, and virtual communication tools. Employees must be able to sit for extended periods, communicate effectively.

Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver's license and meet the organization's driving eligibility requirements.

Reasonable accommodations will be provided to enable individuals with disabilities to perform essential functions.

Monday - Friday. 8:00 am - 5:00 pm, EST