Clinical Reviewer RN - Alabama

Anacalifornia; Sacramento (CA); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

Remote work option

Annual workspace stipend

Job summary

Comagine Health is seeking a Clinical Utilization Review Nurse (RN) for a remote, full-time role based primarily in Alabama. You will assess medical necessity and quality of care through prospective, concurrent, and retrospective reviews, ensuring compliance with clinical criteria, policies, and Alabama contract requirements.

Qualified candidates hold a BA/BS in Nursing, current Alabama RN licensure, and at least three years of direct patient care experience.

Qualifications

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

Responsibilities

• Apply Alabama Medicaid program criteria to determine medical necessity.
• Complete reviews within state and federal timelines.
• Consult with Physician Advisor for cases needing medical justification.
• Collaborate with administrative support as needed.
• Identify customer needs and respond promptly to inquiries.
• Anticipate delays and keep customers informed of status.

Education

BA/BS in Nursing

Active RN license

3+ years direct patient care

Job description

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.