[Hiring] Clinical Review Supervisor @COMAGINE HEALTH

Role Description

This role requires that the employee is an active RN and based in Alabama. The Supervisor, Clinical Review plays a critical role in providing operational supervision of clinical staff who conduct utilization review and/or specialty reviews. The Clinical Review supervisor will guide, monitor, and train clinical reviewers to identify medical necessity/medical appropriateness as identified by specific criteria, contract guidelines, and/or organizational clinical criteria.

Qualifications

• All nurse reviewers will be located and licensed within Alabama and in good standing with the Alabama Board of Nursing and Board of Medical Examiners.
• Experience with:
  • Performing PA reviews
  • Long-term care including nursing home, ICF/IID, swing bed, PEC, and inpatient psychiatric facilities
• Minimum of 3 years of clinical experience in a healthcare setting.
• At least 1 year of supervisory or team leadership experience in a clinical environment.
• 1 year of medical management / utilization review experience.
• Strong knowledge of clinical review processes, healthcare regulations, and medical terminology.
• Proficiency with electronic medical records (EMR) systems and clinical documentation standards.

Requirements

• Preferred Qualifications:
  • LCSW, LPC licensure or equivalent clinical certification.
  • 3 years of medical management / utilization review experience.
  • Experience with health plan operations or managed care organizations.
  • Familiarity with state and federal healthcare regulations, including HIPAA and CMS guidelines.
  • 5 years of clinical (direct patient care) experience.

Responsibilities

• Display critical thinking abilities, strong leadership skills, wise decision-making abilities, organized, knowledgeable, and excellent communicator.
• Demonstrated leadership ability within a team, including management of personnel, meeting targets, and facilitating process improvement efforts.
• Competent in understanding medical/clinical terminology, diagnoses, and documentation.

Skills

• Strong communication and interpersonal skills for collaborating with multidisciplinary teams and resolving clinical issues efficiently.
• Analytical skills to interpret clinical data, identify trends, and implement quality improvement initiatives.
• Proficiency with EMR systems and clinical software for accurate documentation review and reporting.
• Preferred skills such as advanced certifications and familiarity with regulatory frameworks to enhance the supervisor’s ability to navigate complex healthcare environments and drive continuous improvement in clinical review processes.

Benefits

• Medical, dental and vision insurance.
• Paid time off for vacation, illness and volunteering.
• Retirement savings plan with employer contribution.
• Adoption financial assistance.
• Paid parental leave.
• And much more!