Clinical Reviewer RN - Alabama
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. Position Overview 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 responds 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. Education & Experience BA/BS in Nursing Active RN in the Alabama. Minimum of 3 years of direct patient care (clinical) experience Licensure Current, active, unrestricted RN license 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 Equal Opportunity Employer Comagine Health is an equal opportunity employer and is committed to creating a diverse, equitable, and inclusive workplace. 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, 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.