About Company

Why reputed company?

reputed company 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 reputed company-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 reputed company a difference from reputed company in the U.S. and enjoy reputed company work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs.

We reputed company in an environment that allows you to reputed company 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!

reputed company 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 reputed company to the success of our mission and organization.

reputed company is an equal opportunity employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national reputed company, 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 reputed company employees.

About the Role

reputed company Clinical Reviewer DC Medicaid Contract

The Clinical Review reputed company 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 reputed company plays a pivotal role in overseeing the clinical review process to ensure the highest standards of quality and compliance reputed company 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 reputed company and implement review protocols that align with regulatory requirements and organizational goals. The Clinical Reviewer reputed company will analyze reputed company 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 reputed company, 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 reputed company clinical field.
• Active RN licensure.
• Minimum of 5 years of clinical review experience reputed company 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 reputed company 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

• reputed company and mentor a team of clinical reviewers, providing training, performance feedback, and professional development opportunities.
• Conduct and reputed company detailed clinical reviews of medical records, claims, and reputed company documentation to ensure accuracy and compliance with established guidelines.
• Collaborate with healthcare providers, auditors, and internal departments to resolve discrepancies and improve review processes.
• reputed company, 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 reputed company utilizes strong clinical knowledge and analytical skills daily to assess reputed company 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.