Clinical Reviewer

🔥 23 minutes ago

🐻 Alaska – Remote

🐻 Alaska – Remote

💵 $79k - $104k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

👻 Ghost score 0%

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Comagine Health

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1973

💼 Consulting

🏥 Healthcare

🤝 Non-profit

Consulting • Healthcare • Non-profit

Comagine Health is a national nonprofit health care consulting organization that partners with providers, payers, public agencies, community organizations and consumers to improve health care quality, equity, and outcomes. It offers systemwide quality improvement, care management, data solutions, research and evaluation, and COVID-19 response services, using health information exchange and health IT to inform public health surveillance and program design. Comagine focuses on supporting community health, behavioral health, and patient-centered initiatives through technical assistance, evaluation, and collaborative systems-level work.

📋 Description

• Assess the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective utilization management reviews • Apply clinical review criteria, organizational policies, guidelines, and InterQual screening tools • Consult physician/practitioner consultants when services do not meet medical necessity criteria • Collaborate with internal teams and refer cases for additional review or escalation • Refer cases to management when required • Provide clinical and utilization review subject matter expertise • Respond to provider, customer, and stakeholder questions regarding determinations and processes • Conduct outreach to providers, case managers, consultants, and community support coordinators to obtain additional clinical information • Maintain accurate documentation and comply with regulatory and contract standards • Support high-quality, appropriate, and cost-effective care while ensuring compliance with clinical criteria, organizational policies, and Alaska-specific contract requirements • Work remotely in a home-based setting using computers, phones, and virtual communication tools • Occasional travel for meetings, training, or work-related events may be required

🎯 Requirements

• BA/BS in Nursing • An equivalent combination of education and/or related experience may be considered depending on contract • Minimum of 3 years of direct patient care (clinical) experience • Current, active, unrestricted RN license • Must meet Alaska state and contract-specific requirements • Experience with InterQual Criteria • Strong proficiency in Microsoft Office Suite • Familiarity with database systems • Excellent written and verbal communication skills • Strong organizational, analytical, and problem-solving abilities • Ability to manage multiple priorities in a fully remote, team-based environment • Reliable, secure internet connection • Must maintain licensure eligibility for assigned state contract • Ability to sit for extended periods and communicate effectively • Valid driver's license and driving eligibility requirements where applicable

🏖️ Benefits

• 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 • Annual stipend for workspace enhancement • Remote work support • Work-life balance • Reasonable accommodations for individuals with disabilities