Medical Clinical Reviewer, Clinical Program Specialist – Managing Consultant

This is a fully remote position, open to applicants in Virginia.

📋 Description

• Assess healthcare services, procedures, and treatment activities for clinical suitability, medical necessity, and alignment with care standards.

• Evaluate patient care pathways and treatment advancements across various clinical conditions and specialties.

• Analyze the interrelations among diagnoses, procedures, imaging, laboratory services, therapies, medications, supplies, and follow-up care.

• Examine clinical documentation requirements and practices that support healthcare decision-making and service delivery.

• Identify gaps, inconsistencies, missing services, and further clinical considerations.

• Collaborate with stakeholders in coding, reimbursement, analytics, and operations.

• Validate proposed methodologies against real-world healthcare delivery, provider workflows, and patient care experiences.

• Assist in developing clinical rationale, inclusion criteria, exclusions, assumptions, and relevant documentation.

• Engage in stakeholder reviews, governance, quality control, and validation processes.

• Record findings, recommendations, risks, and the rationale behind decisions for implementation and program management.

• Provide clinical and operational expertise to support federal health programs.

⛳️ Requirements

• Valid clinical licensure as a Registered Nurse (RN), Nurse Practitioner (NP), Physician Assistant (PA), Physical Therapist (PT), Occupational Therapist (OT), or an equivalent clinical credential.

• Over 5 years of experience in clinical practice, utilization management, prior authorization, medical review, clinical documentation improvement, payment integrity, case management, provider operations, or healthcare program operations.

• Proficient in reviewing medical records, clinical documentation, treatment plans, or healthcare services for clinical and operational decision-making.

• Strong comprehension of patient care pathways, healthcare service utilization, treatment progression, and care standards.

• Familiarity with payer, provider, Medicare, Medicaid, TRICARE, VA, commercial, or federal healthcare environments.

• Capability to convey complex clinical concepts to operational, technical, and non-clinical stakeholders.

• One or more of the following certifications: Registered Nurse (RN), Certified Clinical Documentation Specialist (CCDS), Certified Risk Adjustment Coder (CRC), Certified in Healthcare Compliance (CHC), Certified Professional Coder (CPC), Certified Case Manager (CCM), or Certified Professional in Healthcare Quality (CPHQ).

• Ability to obtain Public Trust clearance.

• Willingness to travel up to 25% as required or expected.

• Experience supporting large-scale federal health, payer, or provider programs is preferred.

• Experience in translating clinical review findings into business rules, audit concepts, decision frameworks, or operational guidance is preferred.

• Familiarity with claims, authorization, encounter, or utilization data is preferred.

• Experience in supporting governance, validation, quality review, or implementation activities is preferred.

• Preference for candidates located in the Washington, DC metro area.

🏝️ Benefits

• Medical, Rx, Dental & Vision Insurance.

• Personal and Family Sick Time & Company Paid Holidays.

• Position may qualify for a discretionary variable incentive bonus.

• Parental Leave and Adoption Assistance.

• 401(k) Retirement Plan.

• Basic Life & Supplemental Life Insurance.

• 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.

• Flexible benefits package.