Clinical Reviewer

COMAGINE HEALTH

5d•Remote

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 go beyond merely providing a remote work option; we support and embrace it. 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. That’s why we offer benefits that include: 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. And much more! POSITION OVERVIEW We are seeking a Clinical Utilization Review Nurse (RN) 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 New Mexico.

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
Full-Time
100% Remote (United States)
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