[Hiring] Clinical Reviewer RN @COMAGINE HEALTH

Role Description

We are seeking Clinical Utilization Review Nurses (RN) based in Alabama 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 Alabama.

Key Responsibilities

• Apply Alabama Medicaid program criteria and guidelines to determine the medical necessity of health care services.
• Complete reviews within timelines established by all applicable state and federal requirements.
• Consult and forward to a Physician Advisor/ Consulting Physician all cases for which a medical necessity determination cannot be rendered.
• Work with administrative support, as appropriate.
• Identify customer needs and expectations and respond to them in a timely and effective manner.
• Anticipate and prevent delays or other adverse impacts to customers and keep them informed about the status of pending actions and inquiries.
• Attend, upon request, Medicaid meetings, fair hearings, meetings, and hearings of legislative committees and interested governmental bodies, agencies, and officers.

Qualifications

• BA/BS in Nursing
• Active RN in Alabama
• Minimum of 3 years of direct patient care (clinical) experience

Requirements

• Current, active, unrestricted RN license in Alabama
• All nurse reviewers will be located and licensed within Alabama and in good standing with the Alabama Board of Nursing and Board of Medical Examiners.
• Experience with performing PA reviews
• Experience in long-term care including nursing home, ICF/IID, swing bed, PEC, and inpatient psychiatric facilities
• Experience in provider relations
• Experience in reporting

Work Environment

• Reliable, secure internet connection required
• Must maintain licensure eligibility for assigned state contract

Physical Requirements & Work Environment

• This position is primarily remote and performed in a home-based setting, requiring reliable internet access and a workspace free from significant distractions.
• The role involves frequent use of computers, phones, and virtual communication tools.
• Employees must be able to sit for extended periods and communicate effectively.
• Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver’s license and meet the organization’s driving eligibility requirements.
• Occasional travel may be required for meetings, training, or other work-related events.
• Reasonable accommodations will be provided to enable individuals with disabilities to perform essential functions.