Clinical Reviewer

COMAGINE HEALTH

1d

About The Position

Comagine Health is seeking a Clinical Reviewer - On-Call - PRN (less than 20 hours per week) to assess the medical necessity, quality, and appropriateness of healthcare services. This role conducts prospective, concurrent, and retrospective utilization management reviews to support high-quality, cost-effective care while ensuring compliance with evidence-based guidelines, regulatory requirements, and organizational policies.

Requirements

• Bachelor’s degree (BA/BS) required
• BS in Nursing
• Current, active, unrestricted clinical licensure required
• Minimum of 3 years of clinical (direct patient care) experience
• Intermediate communication skills
• Intermediate interpersonal and relationship-building skills
• Foundational professionalism and integrity
• Foundational work ethic and reliability
• Intermediate clinical knowledge

Nice To Haves

• 1 year of utilization review or medical management experience preferred

Responsibilities

• Conduct prospective (pre-authorization), concurrent/continued stay, and retrospective utilization management reviews to ensure appropriate use of healthcare resources.
• Conduct compliance and/or quality audits of medical records/patient charts for accuracy, completeness, and adherence to established standards.
• Evaluate requests for healthcare services using clinical review criteria, organizational policies, regulatory requirements, and evidence-based guidelines to determine medical necessity and appropriateness.
• Perform compliance and quality audits of medical records and patient charts for accuracy, completeness, and adherence to established standards.
• Consult with physician or practitioner consultants when reviews do not meet clinical criteria and refer cases to other clinicians as appropriate.
• Provide day-to-day oversight and monitoring of non-clinical staff performing non-clinical support activities, as applicable, and offer performance feedback to the supervisor.

What This Job Offers

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