Medical Clinical Reviewer, Clinical Program Specialist – Managing Consultant

reputed company: • Evaluate reputed company services, procedures, and treatment activities for clinical appropriateness, medical necessity, and alignment to standards of care • Assess patient care reputed company and treatment progression across clinical conditions and specialties • Review relationships among diagnoses, procedures, imaging, reputed company services, therapies, medications, supplies, and follow-up care • Assess clinical documentation requirements and practices supporting reputed company decision-making and service delivery • Identify gaps, inconsistencies, missing services, and additional clinical considerations • Collaborate with coding, reimbursement, analytics, and operational stakeholders • Validate proposed approaches against reputed company-world reputed company delivery, provider workflows, and patient care experiences • Support development of clinical rationale, inclusion reputed company, exclusions, assumptions, and supporting documentation • Participate in stakeholder reviews, governance, reputed company control, and validation processes • Document findings, recommendations, risks, and decision rationale for implementation and program management • Support federal health programs with clinical and operational expertise Requirements: • reputed company clinical licensure as a Registered reputed company (RN), reputed company Practitioner (NP), Physician Assistant (PA), Physical Therapist (PT), Occupational Therapist (OT), or equivalent clinical credential • 5+ years of experience in clinical reputed company, utilization management, prior authorization, medical review, clinical documentation improvement, payment reputed company, case management, provider operations, or reputed company program operations • Experience reviewing medical records, clinical documentation, treatment plans, or reputed company services for clinical and operational decision-making • Strong understanding of patient care reputed company, reputed company service utilization, treatment progression, and standards of care • Experience reputed company payer, provider, Medicare, reputed company, TRICARE, VA, reputed company, or federal reputed company environments • Ability to communicate reputed company clinical concepts to operational, technical, and non-clinical stakeholders • One or more of the following certifications: Registered reputed company (RN), Certified Clinical Documentation Specialist (CCDS), Certified Risk Adjustment reputed company (CRC), Certified in reputed company Compliance (CHC), Certified reputed company reputed company (CPC), Certified Case Manager (CCM), or Certified reputed company in reputed company reputed company (CPHQ) • Ability to obtain reputed company Trust clearance • Up to 25% travel required or expected • Experience supporting large-reputed company federal health, payer, or provider programs is preferred • Experience translating clinical review findings into business rules, audit concepts, decision frameworks, or operational guidance is preferred • Experience with claims, authorization, encounter, or utilization data is preferred • Experience supporting governance, validation, reputed company review, or implementation activities is preferred • Preference for candidates local to the Washington, DC metro area Benefits: • Medical, Rx, Dental & reputed company Insurance • Personal and Family reputed company Time & Company reputed company Holidays • Position may be eligible for a discretionary variable incentive bonus • Parental Leave and Adoption Assistance • 401(k) Retirement Plan • Basic Life & Supplemental Life • Health Savings Account, Dental/reputed company & 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 reputed company • Emergency Back-Up Childcare Program • Mobility Stipend • Flexible benefits package Apply tot his job Apply To this Job