[Hiring] Clinical Reviewer Registered Nurse @COMAGINE HEALTH

Role Description

This is an excellent opportunity for an experienced Registered Nurse who wants to transition from direct patient care into a remote clinical review role or continue building a career in clinical review and healthcare quality.

The Clinical Reviewer is responsible for assessing the medical necessity, appropriateness, and quality of healthcare services through prospective, concurrent, and retrospective clinical reviews. In this role, you will:

• Conduct prospective (pre-authorization), concurrent (continued stay), and retrospective clinical reviews for inpatient and outpatient services, including orthopedic and spine surgery and complex imaging.
• Evaluate healthcare service requests to determine whether established clinical criteria are met and assess the appropriateness of care.
• Apply established clinical review criteria, organizational policies, regulatory requirements, and evidence-based guidelines.
• Review clinical documentation and medical records to support accurate and timely determinations.
• Consult with physician and practitioner consultants when cases do not meet established clinical review criteria.
• Refer cases to appropriate clinical professionals for additional evaluation when indicated.
• Collaborate with internal clinical teams to support consistent, high-quality review practices.
• Ensure clinical reviews are appropriately documented and completed in accordance with established procedures and contractual expectations.
• Support compliance with Washington L&I contract requirements and applicable clinical review standards.
• Provide daily oversight and monitoring of non-clinical support activities, as appropriate.
• Offer feedback to supervisors regarding the performance and effectiveness of non-clinical support processes.
• Contribute to continuous quality improvement initiatives and efficient review operations.

Qualifications

• Current, active, unrestricted Registered Nurse (RN) license in the State of Washington.
• Minimum of five (5) years of clinical nursing experience providing direct patient care.
• Experience applying clinical judgment to evaluate patient care, treatment plans, and medical documentation.
• Ability to interpret and apply clinical guidelines, medical necessity criteria, and established healthcare standards.
• Strong clinical assessment and critical-thinking skills.
• Excellent written and verbal communication skills.
• Ability to review and interpret complex clinical documentation.
• Strong organizational skills with attention to detail and accuracy.
• Ability to work independently, prioritize responsibilities, and meet established deadlines.
• Proficiency with electronic medical records, clinical documentation systems, and computer-based applications.
• Demonstrated professionalism, reliability, and commitment to confidentiality.

Requirements

• Bachelor's degree (BA/BS) preferred.
• Clinical experience in an Intensive Care Unit (ICU) and/or Emergency Department (ER) setting preferred.
• Familiarity with medical necessity criteria and evidence-based clinical guidelines preferred.
• Experience collaborating with physician reviewers and multidisciplinary clinical teams preferred.

Benefits

• Remote work opportunity within Washington State.
• Comprehensive medical, dental, and vision insurance.
• 401(k) retirement plan with company match.
• Generous paid time off and paid holidays.
• Annual home office stipend, provided through payroll in January for existing employees and upon hire for new employees.
• Professional development and continuing education opportunities.
• Collaborative, supportive, and mission-driven work environment.
• Opportunity to make a meaningful impact on healthcare quality and patient outcomes.

Company Description

At Comagine Health, we are passionate about improving the quality, safety, and value of healthcare. As a national nonprofit healthcare consulting organization, we partner with healthcare providers, government agencies, and communities to improve health outcomes and ensure individuals receive appropriate, high-quality care.

Our mission-driven culture provides opportunities for healthcare professionals to apply their clinical expertise in meaningful ways while enjoying the flexibility of a remote work environment.