Clinical Reviewer (RN) Qualified Intellectual Disabilities Pro

COMAGINE HEALTH; Washington (District of Columbia); Remote; USD 65,000 - 90,000; Part time

Benefits offered by this job

Annual workspace stipend

Job summary

Comagine Health is seeking an RN to perform Clinical Review work and QIDP reviews as part of a remote team. The role is a (.5 FTE) QIDP and (.5 FTE) nurse clinical reviewer, primarily serving Alabama Medicaid program needs.

The position requires Alabama RN licensure and at least 3 years of direct patient care. Strong organizational skills and ability to work remotely are essential, with occasional travel for meetings as needed.

Qualifications

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

Responsibilities

• Apply Alabama Medicaid program criteria to determine medical necessity of health care services.
• Experience with facilities serving individuals with intellectual disabilities (ICF/IID) is preferred.
• Complete reviews within timelines set by state and federal requirements.
• Consult with Physician Advisor on cases needing further medical necessity determinations.
• Coordinate with administrative support as appropriate.
• Identify customer needs and respond in a timely and effective manner.
• Attend Medicaid meetings, fair hearings, and related government meetings when requested.

Skills

Nursing

Education

BA/BS in Nursing

Active RN license - Alabama

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.

Benefits & Perks

• An annual stipend gives you the freedom to enhance your workspace with options that suit your needs.

Position OverviewWe 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 licenseAlabama

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 relationsReportingWork Environment

Work Environment

• Reliable, secure internet connection required
• Must maintain licensure eligibility for assigned state contract
• Equal Opportunity Employer

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. PI287350806