Clinical Reviewer, Registered Nurse (RN)

🔥 0 minutes ago

☕ Washington – Remote

☕ Washington – Remote

💵 $80k - $100k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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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

• 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

🎯 Requirements

• 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 • Bachelor's degree (BA/BS) is preferred • Clinical experience in an Intensive Care Unit (ICU) and/or Emergency Department (ER) setting is preferred • Familiarity with medical necessity criteria and evidence-based clinical guidelines is preferred • Experience collaborating with physician reviewers and multidisciplinary clinical teams is preferred • Reliable internet access and a dedicated workspace free from significant distractions • Ability to maintain the confidentiality of protected health information • Comfort using electronic medical records, clinical review applications, and virtual communication tools

🏖️ 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 • 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