Lisa Howell
Senior Clinical Reviewer @Comagine Health
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WORK HISTORY
Senior Clinical Reviewer @Comagine Health
Conduct clinical and regulatory reviews supporting External Quality Review (EQR) activities for Medicaid managed care programs. Evaluate managed care organization (MCO) processes related to grievances, appeals, and prior authorization determinations to assess compliance with federal CMS requirements, state Medicaid contracts, and evidence-based clinical standards.Analyze case files, clinical documentation, and health plan policies to determine adherence to utilization management requirements, including medical necessity determinations and regulatory timeliness standards. Identify trends, compliance risks, and opportunities for quality improvement through structured audit methodologies.Serve as activity lead for assigned audit components, coordinating review activities, organizing documentation workflows, and ensuring consistency in clinical review methodology across the review team. Provide subject matter expertise on utilization management, appeals processes, and Medicaid regulatory requirements.Collaborate with interdisciplinary reviewers to synthesize findings, support objective audit determinations, and contribute to External Quality Review reports provided to state Medicaid agencies.Focus areas include:• Medicaid Managed Care Compliance• External Quality Review (EQR)• Utilization Management & Prior Authorization• Appeals and Grievances Review• Medical Necessity & Regulatory Timeliness• CMS and State Contract Compliance
EDUCATION
Community College of Philadelphia
AAS, Nursing
Western Governors University
Master of Business Administration - MBA, Health/Health Care Administration/Management
Temple University
Nursing
University of Phoenix
BSN, Nursing
ABOUT LISA HOWELL
Registered Nurse with an MBA in Healthcare Administration and more than 30 years of experience across healthcare quality, utilization management, regulatory compliance, and clinical program leadership. My career has focused on strengthening healthcare systems by improving quality, ensuring regulatory compliance, and supporting clinical decision-making that protects both patients and providers.I currently serve as a Senior Clinical Reviewer with Comagine Health, where I support External Quality Review (EQR) activities for Medicaid managed care programs. My work includes evaluating grievances, appeals, and prior authorization determinations to assess compliance with CMS regulations, state Medicaid contracts, and evidence-based clinical standards. Through structured clinical review and audit methodologies, I help identify opportunities to strengthen accountability, improve processes, and enhance healthcare quality across managed care programs.Throughout my career, I have led complex initiatives involving electronic health records, utilization management, case management, correctional healthier and quality improvement. I bring experience interpreting payer policies, assessing medical necessity determinations, and guiding programs toward regulatory compliance and operational excellence. I am passionate about translating regulatory and clinical requirements into practical processes that improve both patient outcomes and organizational performance.Equally important to my professional philosophy is the belief that strong healthcare leadership requires a commitment to personal wellness and resilience. Healthcare professionals operate in demanding environments, and prioritizing health, balance, and lifelong learning is essential to preventing burnout and sustaining meaningful impact in the field.
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