Clinical Review Manager

Overview

We need hope-bringers and changemakers — because the work we all do matters. If you’re passionate about making an impact with your time and being someone’s light in the darkness, we want you on our team.

 

Come Join Us to Do Mission-Based, Meaningful Work

 

Who We Are

Gaudenzia is one of the largest nonprofit providers of treatment to people with substance use and co-occurring disorders in the nation. We operate in Pennsylvania, Delaware, Maryland, and Washington, D.C.  

 

Our caring, compassionate team is on a mission to save thousands of lives each year and bring hope to people devastated by substance use disorder. Together, we help individuals, families, and communities heal and thrive in the face of one of the most devastating public health crises of our time.

 

As our organization grows and evolves to meet the needs of our clients and communities, we’re seeking passionate, empathic individuals to help us make an impact. With your help, we can turn the tide on substance use disorder.    

Who we’re looking for:

 

The Clinical Review Manager plays a pivotal role in overseeing the clinical review process for substance use disorder treatment authorizations. This position requires a blend of billing expertise, leadership skills, and a thorough understanding of utilization management to ensure the highest standards of care and compliance with established guidelines.

We are seeking individuals who excel in leadership roles, can work independently, and are adept at managing deadlines. The ideal candidate will have extensive experience in utilization management, as well as familiarity with DC and Comagine. This role involves significant interaction with healthcare providers, internal program management, and external stakeholders to ensure the accuracy and timeliness of clinical reviews. This individual will work closely with the Clinical Review Clinician.

Key responsibilities include managing the clinical review process, conducting thorough audits, maintaining accurate records of authorization decisions, and collaborating with other team members to achieve program goals and objectives. The Clinical Review Manager is also responsible for staying up-to-date with the latest clinical guidelines and best practices, providing training and support to the clinical review team, and ensuring compliance with all regulatory requirements.

The work is performed with considerable independence, adhering to established regulations, policies, and procedures. The Clinical Review Manager reports to the Operations Director, who reviews and supervises the work.

Responsibilities

Your responsibilities in this role may include:

 

• Treat all clients and staff with dignity and respect
• Supervise audit and review process and provide documented recommendations based on appropriate guidelines
• Review and approve documentation associated with applicable state regulations, insurance requirements, and relevant treatment guidelines
• Ensure accurate, up-to-date records, including intake, records of referral, and funding source documentation are compiled and stored within the electronic health record system within the required timeframes
• Assist clinical staff in quality improvement projects by providing instructive feedback
• Resolve client care issues by working one-on-one with community providers and staff to address issues in the determination process
• Establish and maintain positive relationships with funding, referral, and regulatory agencies
• Provide information by responding to queries from funding sources, sorting and distributing messages and documents, and preparing information for determinations
• Improve quality results by studying and evaluating procedures and processes, and recommending changes if needed
• Other duties as assigned by the Operations Director, or designee
• Knowledge of Managed Care, including DC and Comagine preferred
• Knowledge of regulatory, licensing, and accreditation standards
• Knowledge of utilization review process
• Knowledge and ability to work with electronic health record systems
• Knowledge of substance use and mental health disorder treatment programs
• Knowledge of quality improvement processes, including the ability to evaluate and recommend changes to enhance service quality
• Ability to communicate effectively, both verbally and in writing
• Ability to successfully work with others from various cultures and backgrounds
• Ability to plan and organize work and prepare appropriate, accurate records, and reports

Ability to establish and maintain effective working relationships with clients, st