Medical Clinical Reviewer, Clinical Program Specialist – Managing Consultant
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Job Description
Clinical reviewer supporting Guidehouse’s federal healthcare programs. Evaluating medical necessity, documentation, care pathways, and operational decisions across complex healthcare environments.
Responsibilities:
- Evaluate healthcare services, procedures, and treatment activities for clinical appropriateness, medical necessity, and alignment to standards of care
- Assess patient care pathways and treatment progression across clinical conditions and specialties
- Review relationships among diagnoses, procedures, imaging, laboratory services, therapies, medications, supplies, and follow-up care
- Assess clinical documentation requirements and practices supporting healthcare 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 real-world healthcare delivery, provider workflows, and patient care experiences
- Support development of clinical rationale, inclusion criteria, exclusions, assumptions, and supporting documentation
- Participate in stakeholder reviews, governance, quality 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:
- Active clinical licensure as a Registered Nurse (RN), Nurse Practitioner (NP), Physician Assistant (PA), Physical Therapist (PT), Occupational Therapist (OT), or equivalent clinical credential
- 5+ years of experience in clinical practice, utilization management, prior authorization, medical review, clinical documentation improvement, payment integrity, case management, provider operations, or healthcare program operations
- Experience reviewing medical records, clinical documentation, treatment plans, or healthcare services for clinical and operational decision-making
- Strong understanding of patient care pathways, healthcare service utilization, treatment progression, and standards of care
- Experience within payer, provider, Medicare, Medicaid, TRICARE, VA, commercial, or federal healthcare environments
- Ability to communicate complex clinical concepts to operational, technical, and non-clinical stakeholders
- One or more of the following certifications: Registered Nurse (RN), Certified Clinical Documentation Specialist (CCDS), Certified Risk Adjustment Coder (CRC), Certified in Healthcare Compliance (CHC), Certified Professional Coder (CPC), Certified Case Manager (CCM), or Certified Professional in Healthcare Quality (CPHQ)
- Ability to obtain Public Trust clearance
- Up to 25% travel required or expected
- Experience supporting large-scale 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, quality review, or implementation activities is preferred
- Preference for candidates local to the Washington, DC metro area
Benefits:
- Medical, Rx, Dental & Vision Insurance
- Personal and Family Sick Time & Company Paid 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/Vision & 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 Outreach
- Emergency Back-Up Childcare Program
- Mobility Stipend
- Flexible benefits package
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