Clinical Reviewer RN - Alabama

COMAGINE HEALTH

1d • Remote

About The Position

We are seeking Clinical Utilization Review Nurses (RN) based in Alabama to assess the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective utilization management reviews. This full-time, remote position supports high-quality, appropriate, and cost-effective care while ensuring compliance with clinical criteria, organizational policies, and contract requirements specific to Alabama.

Requirements

• BA/BS in Nursing
• Active RN in the Alabama.
• Minimum of 3 years of direct patient care (clinical) experience
• Current, active, unrestricted RN license
• Alabama
• 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.
• Reliable, secure internet connection required
• Must maintain licensure eligibility for assigned state contract

Nice To Haves

• Performing PA reviews
• Long-term care including nursing home, ICF/IID, swing bed, PEC, and inpatient psychiatric facilities
• Provider relations
• Reporting

Responsibilities

• Apply Alabama Medicaid program criteria and guidelines to determine the medical necessity of health care services.
• Complete reviews within timelines established by all applicable state and federal requirements.
• Consult and forward to a Physician Advisor/ Consulting Physician all cases for which a medical necessity determination cannot be rendered.
• Work with administrative support, as appropriate.
• Identify customer needs and expectations and responds to them in a timely and effective manner.
• Anticipate and prevent delays or other adverse impacts to customers and keep them informed about the status of pending actions and inquiries.
• Attend, upon request, Medicaid meetings, fair hearings, meetings, and hearings of legislative committees and interested governmental bodies, agencies, and officers.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 101-250 employees