Medical Clinical Reviewer / Clinical Program Specialist | Managi

Job Family :
Strategy & Transformation Consulting

Travel Required :
Up to 25%

Clearance Required :
Ability to Obtain Public Trust

What You Will Do:

We are seeking experienced clinicians to support federal health programs by providing expertise in healthcare delivery, clinical documentation, utilization management, medical necessity review, clinical operations, and patient care pathways.

In this role, you will help evaluate how healthcare services are delivered, documented, reviewed, and operationalized across complex healthcare environments. Working closely with coding, reimbursement, operational, and analytics stakeholders, you will apply your clinical expertise to assess treatment pathways, care delivery patterns, documentation requirements, service relationships, and healthcare utilization to support consistent program decision-making and operational implementation.

The ideal candidate brings experience in one or more areas including clinical practice, utilization management, prior authorization, medical review, clinical documentation improvement, case management, payment integrity, or healthcare operations. This individual should be comfortable evaluating healthcare services from both a clinical and operational perspective and translating healthcare delivery requirements into practical recommendations that support program objectives, stakeholder decision-making, and scalable healthcare processes. Responsibilities will include:

• 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 a variety of clinical conditions and specialties.
• Review relationships among diagnoses, procedures, imaging, laboratory services, therapies, medications, supplies, and follow-up care.
• Assess clinical documentation requirements and documentation practices that support healthcare decision-making and service delivery.
• Identify gaps, inconsistencies, missing services, or additional clinical considerations that should be evaluated.
• Collaborate with coding, reimbursement, analytics, and operational stakeholders to evaluate healthcare service relationships and clinical considerations.
• Validate that proposed approaches align with 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 activities, quality control reviews, and validation processes.
• Document findings, recommendations, risks, and decision rationale to support implementation and ongoing program management.

What You Will Need:

• 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 one or more of the following areas: 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 to support clinical and operational decision-making.
• Strong understanding of patient care pathways, healthcare service utilization, treatment progression, and standards of care.
• Experience working 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.
• Candidates should possess 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)
  • Certified Professional in Healthcare Quality (CPHQ)

What Would Be Nice To Have:

• Experience supporting large-scale federal health, payer, or provider programs with complex clinical, operational, or policy requirements.
• Experience translating clinical review findings into practical business rules, audit concepts, decision frameworks, or operational guidance.
• Experience working with claims, authorization, encounter, or utilization data to inform clinical review or program decisions.
• Experience supporting governance, validation, quality review, or implementation activities for healthcare programs or payment integrity initiatives.

What We Offer :

Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.

Benefits include:

• 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

About Guidehouse

Guidehouse is an Equal Opportunity Employer-Protected Veterans, Individuals with Disabilities or any other basis protected by law, ordinance, or regulation.

Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.

If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at RecruitingAccommodation@guidehouse.com . All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.

All communication regarding recruitment for a Guidehouse position will be sent from Guidehouse email domains including @guidehouse.com or guidehouse@myworkday.com . Correspondence received by an applicant from any other domain should be considered unauthorized and will not be honored by Guidehouse. Note that Guidehouse will never charge a fee or require a money transfer at any stage of the recruitment process and does not collect fees from educational institutions for participation in a recruitment event. Never provide your banking information to a third party purporting to need that information to proceed in the hiring process.

If any person or organization demands money related to a job opportunity with Guidehouse, please report the matter to Guidehouse's Ethics Hotline. If you want to check the validity of correspondence you have received, please contact recruiting@guidehouse.com . Guidehouse is not responsible for losses incurred (monetary or otherwise) from an applicant's dealings with unauthorized third parties.

Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.