Senior Clinical Reviewer for External Quality Review

4 days ago

Seattle, Washington, United States Qualis Health Full time

Comagine Health is seeking a Senior Clinical Reviewer for External Quality Review (EQR) Services to support state external quality review contracts.

This role involves 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.

The successful candidate will contribute to the development of reports and other deliverables, and communicate audit findings and recommendations to state Medicaid agencies.

Key Responsibilities:

  • 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.

Comagine Health is a national, nonprofit, health care consulting firm that works collaboratively with patients, providers, payers, and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system.

We are a trusted, neutral party that works 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.

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