Clinical Reviewer
About The Position
Comagine Health is a national, mission-driven, nonprofit organization that has engaged in health care quality consulting and quality improvement services for more than 50 years. We are leaders in assisting front-line providers and engaging health care partners to improve care delivery and patient outcomes. Our talented remote workforce spans the country and plays a vital role in our success. We offer opportunities to make a difference from anywhere in the U.S. and enjoy better work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs. We believe in an environment that allows you to thrive both personally and professionally.
Requirements
- BA/BS in Nursing
- Equivalent combination of education and/or related experience may be considered depending on contract
- Minimum of 3 years of direct patient care (clinical) experience
- Current, active, unrestricted RN license
- Must meet New Mexico state and contract-specific requirements
- Experience with InterQual Criteria
- Strong proficiency in Microsoft Office Suite and familiarity with database systems
- Excellent written and verbal communication skills
- Strong organizational, analytical, and problem-solving abilities
- Ability to manage multiple priorities in a fully remote, team-based environment
- Reliable, secure internet connection required
- Must maintain licensure eligibility for assigned state contract
Responsibilities
- Conduct prospective, concurrent, and retrospective utilization management reviews
- Apply clinical review criteria, organizational policies, guidelines, and screening tools (InterQual)
- Consult with physician/practitioner consultants when services do not meet medical necessity criteria
- Collaborate with internal teams and refer cases for additional review or escalation as appropriate
- Refer cases to management when required
- Provide clinical and utilization review subject matter expertise
- Respond to provider, customer, and stakeholder questions regarding determinations and processes
- Conduct outreach to providers, case managers, consultants, and community support coordinators to obtain additional clinical information
- Maintain accurate documentation and comply with all regulatory and contract standards
Benefits
- Medical, dental and vision insurance
- Paid time off for vacation, illness, and volunteering
- Retirement savings plan with employer contribution
- Adoption financial assistance
- Paid parental leave
- Annual stipend for workspace enhancement
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
