[Hiring] Clinical Reviewer (RN) Qualified Intellectual Disabilities Pro @COMAGINE HEALTH

Role Description

We are seeking an RN to perform Clinical Review work and QIDP reviews work. Team member will serve as the QIDP (.5 FTE) and as a nurse clinical reviewer (.5 FTE).

Key Responsibilities

• Apply Alabama Medicaid program criteria and guidelines to determine the medical necessity of health care services.
• Intermediate Care Facilities for Individuals with Intellectual Disabilities experience.
• 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

Licensure

• Current, active, unrestricted RN license in Alabama

Required Skills & Competencies

• 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.
• Long-term care including nursing home, ICF/IID, swing bed, PEC, and inpatient psychiatric facilities.
• Provider relations.
• 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.