Comagine Health is seeking candidates for a Senior Clinical Reviewer for External Quality Review (EQR) Services. In this role, you are responsible for supporting state external quality review contracts by leading and coordinating prior authorization and other audit activities, coordinating with internal teams on project timelines and deliverables, analyzing health plan data, and conducting audit reviews. You will contribute to the development of reports and other deliverables, and communicate audit findings and recommendations to state Medicaid agencies.
Some key responsibilities include:
- Provide daily oversight and monitoring of the project/contract, deliverables and staff supporting the activities.
- Act as a resource (i.e., subject matter expert) for project/contract staff and other non-clinical staff regarding audit processes, and clinical/utilization management/prior authorization matters.
- Ensure staff supporting project/contract activities have the tools and resources needed to complete their work in a high-quality manner.
- Assist with initial orientation and training of new staff assigned to EQR projects/contracts.
- Maintain and monitor individual and team-level performance expectations for deliverables.
Who is Comagine Health?
Comagine Health is a national, nonprofit, health care consulting firm. We work collaboratively with patients, providers, payers, and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system.
As a trusted, neutral party, we work in our communities to address key, complex health, and health care delivery problems. In all our engagements and initiatives, we draw upon our expertise in quality improvement, care management, health information technology, analytics, and research.
We invite our partners and communities to work with us to improve health and redesign the health care delivery system.
Required Qualifications:
- Bachelor's Degree in Nursing (an equivalent combination of education and/or work experience in a related field may be substituted).
- Current, active, unrestricted RN Licensure required.
- 3 years of clinical (direct patient care) experience.
- 3 years of utilization review (or other medical management) experience including conducting prior authorization reviews.
Desired Qualifications:
- 1 year experience supporting EQR contracts or working for a managed care or similar organization
- Project management experience a plus
Competencies
- Medicaid and/or dual-eligible (Medicaid/Medicare) managed care experience, preferred.
- Program evaluation/auditing experience in government, hospital, pharmaceutical, immunization, behavioral health, health plan, state
- Medicaid agency or other healthcare related field, preferred.
- Effective written and verbal communication skills.
Leadership skills
- Provide daily oversight and monitoring of the project/contract, deliverables and staff supporting the activities
- Act as a resource (i.e., subject matter expert) for project/contract staff and other non-clinical staff regarding audit processes, and clinical/utilization management/prior authorization matters
- Ensure staff supporting project/contract activities have the tools and resources needed to complete their work in a high-quality manner
- Assist with initial orientation and training of new staff assigned to EQR projects/contracts
Maintain and monitor individual and team-level performance expectations for deliverables
Some of what you'll do:
Lead EQR Audit Activities
- Provide day-to-day support of contracted EQR activities
Prepare project documentation related to key deliverables and support documentation for assigned contracts and projects - Assist with the creation and/or modification of audit review tools and materials
- Coordinate the collection of documents and medical records from health plans or similar organizations for desk review
- Conduct desk review of documents and medical records received from health plans or similar organizations to prepare for audits
- Analyze health plan data and desk review findings, and document conclusions and recommendations
- Lead the preparation of reports and other deliverables including the collection of materials and information from other team members for inclusion into reports and deliverables
- Provide clinical and utilization management/prior authorization subject matter expertise
- Respond to customer questions or concerns regarding audit findings and recommendations
Ensure the integrity and quality of desk reviews and audit activities
- Apply clinical review criteria, organizational policies, guidelines, and/or other relevant criteria to determine the medical necessity and appropriateness of requested health care services
- Engage and consult with physician/practitioner consultants and/or other clinicians when indicated
- Document desk review / audit determinations and findings in care management information system (e.g., Jiva), and/or designated database
Effectively works with customers and potential customers
- Provide timely, appropriate, and responsive communications and interventions with customers to resolve their concerns, questions, and issues
- Represent Comagine Health products and services through the active participation in customer meetings
- Participate in responses to requests for proposals (RFPs), product development, and other business development activities as needed
Complies with policies and procedures, administrative assignments, and other projects
- Ensure management is informed in a timely manner regarding significant operational issues, progress towards completion of tasks and deliverables, customer complaints, and other relevant topics
- Maintain compliance with organizational policies and procedures
Salary Range: $81,000 - $113,000
The salary range posted reflects the range that Comagine is willing to pay for this position. Salary is determined by many factors, including but not limited to geographic location of where the employee will perform their job duties in addition to their knowledge, skills, education, and relevant work experience.
