Clinical Reviewer

COMAGINE HEALTH

14h•Remote

About The Position

As a Clinical Reviewer, you will assess the medical necessity and quality of healthcare services by conducting prospective, concurrent, and retrospective utilization management reviews. In this fully remote role, you will have the opportunity to work across multiple scopes of work, including but not limited to inpatient, inpatient rehabilitation, long-term acute care, outpatient surgical, and outpatient imaging cases, applying evidence-based clinical criteria to determine medical necessity and document your findings. You will access daily assignments through collaboration tools and the electronic medical records system, working closely with a small, highly efficient team to ensure reviews are completed accurately and within required timelines. We’re looking for someone with strong clinical judgment, the ability to apply medical necessity criteria such as InterQual, and the critical thinking skills needed to evaluate complex healthcare cases. If you are a collaborative team player who thrives in a remote environment, adapts quickly to technology, and can effectively manage competing priorities, we encourage you to apply. Why Comagine Health? 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!

Requirements

Current, active, unrestricted RN Licensure
Bachelor's Degree in Nursing or an equivalent combination of education and/or work experience in a related field may be substituted
3 years of clinical (direct patient care) experience
Reliable, secure internet connection required
Must maintain licensure eligibility for assigned state contract

Nice To Haves

1 year of utilization review or other medical management experience
Licensure in a mental health field
Proficiency in InterQual or similar evidence-based clinical criteria
Strong Microsoft Office Suite proficiency and familiarity with database software programs
Strong organizational skills
Excellent oral and written communication skills
Excellent interpersonal and problem-solving skills
Ability to organize and coordinate multiple simultaneous tasks in a team environment

Responsibilities

Apply clinical review criteria, organizational policies, guidelines, and screens to determine the medical necessity of health care services.
Consult with physician/practitioner consultants when reviews fail clinical review criteria, guidelines, and screens.
Refer cases to other clinicians, when indicated.
As appropriate, provide daily oversight and monitoring of non-clinical staff during their performance of non-clinical support activities; also provide the supervisor with input regarding employees’ performance of these activities.
May perform quality assurance audits and other program support, as assigned by supervisor.
Other duties as assigned