• Clinical Reviewer

    Job Locations US-VA-Glen Allen | US-VA-Chesapeake | US-VA-Alexandria | US-VA-Roanoke | US-VA-Winchester
    Job ID
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
    If this sounds like you, read on!


    This position is responsible for reviewing and authorizing waiver services under CCC Plus according to the approved criteria across the continuum of care to ensure positive member outcomes while controlling costs by performing timely clinical reviews, identifying over/under utilization, and collaborating with the care coordination team to ensure appropriate waiver services are in place for members.


    • Obtains, reviews, and enters clinical information from service providers for the following services: EDCD (agency directed and consumer directed), Tech waiver, respite, Private Duty Nursing, Assistive Technology and/or Maintenance, Environmental Modification and/or Maintenance, Transitions, Nursing Facility, Adult Day Health Care, Services Facilitation, PERS, Hospice, Congregate Nursing, and other LTSS services included under CCC Plus.
    • Utilizes DMAS guidance (such as the EDCD or Nursing Facility manuals) to perform clinical reviews for waiver services
    • Demonstrates comprehensive understanding of criteria for members receiving various waiver services
    • Adheres to expected turnaround times for LTSS requests (5 days standard; 3 days expedited)
    • Refers requests to the Medical Directors to determine medical necessity and appropriateness of care
    • Generates and sends approval letters to members and providers according to VPHP policies and procedures
    • Collaborates with the assigned care coordinator to ensure waiver services are appropriate for the member
    • Participates in interdisciplinary care team meetings
    • Participates in hospital rounds with the care coordination team
    • Participates in VPHP’s ongoing quality improvement process
    • Participates in continuing educational activities as appropriate
    • Other duties as assigned
    • This position provides services and demonstrates the knowledge and ability to meet the specific needs of the following age groups: Infant, Adult, Child, and Geriatric



    • Current Virginia RN Licensure
    • BSN preferred


    • Knowledge of Medicaid waiver services (such as EDCD, Tech, Nursing Facility, Adult Day Health, Private Duty Nursing)
    • Demonstrates ability to negotiate with service providers
    • Demonstrates proficiency in work with various application of Microsoft Office (specifically Excel)
    • Knowledge of community resource options and experience in making appropriate referrals
    • Possess a working knowledge of ICD-10 and CPT-4 coding


    • Minimum of three years clinical experience and/or current managed care experience


    • Physical health sufficient to meet the ergonomic standards and demands of the position.

    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


    Our mission is to inspire healthy living within the communities we serve!


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