Clinical Reviewer Lead

Lead Clinical Reviewer DC Medicaid Contract

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

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