Sr. Clinical Reviewer - EQR

QUALIS HEALTH • Seattle, WA • 3h ago

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 org