Clinical Reviewer (RN) Qualified Intellectual Disabilities Pro

Anacalifornia; Sacramento, Northern (CA, KY); Hybrid; USD 75,000 - 110,000; Full time

Job summary

Comagine Health is seeking an RN to perform Clinical Review work and QIDP reviews. This role is split as a .5 FTE QIDP and a .5 FTE nurse clinical reviewer, primarily remote and home-based.

Ideal candidates will hold a BA/BS in Nursing, an active RN license in Alabama, and at least 3 years of direct patient care experience, with strong skills in provider relations and reporting.

Qualifications

• BA/BS in Nursing required.
• Active RN license in Alabama.
• Minimum 3 years direct patient care experience.

Responsibilities

• Apply Alabama Medicaid program criteria to determine medical necessity.
• Complete reviews within state and federal timelines.
• Consult with Physician Advisor on cases requiring medical necessity determinations.
• Identify customer needs and respond promptly.
• Attend Medicaid meetings and hearings when requested.

Skills

PA reviews

Long-term care experience

Provider relations

Reporting

Education

BA/BS in Nursing

Active RN license

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 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 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.

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