Clinical Reviewer

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. And much more! Position Overview We are seeking a Clinical Utilization Review Nurse (RN) 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 New Mexico. Key Responsibilities Conduct prospective, concurrent, and retrospective utilization management reviews. Apply clinical review criteria, organizational policies, guidelines, and screening tools (InterQual). Consult with physician/practitioner consultants when services do not meet medical necessity criteria. Collaborate with internal teams and refer cases for additional review or escalation as appropriate. 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 all regulatory and contract standards. Education & Experience BA/BS in Nursing. Equivalent combination of education and/or related experience may be considered depending on contract. Minimum of 3 years of direct patient care (clinical) experience. Licensure Current, active, unrestricted RN license. Required Skills & Competencies Experience with InterQual Criteria. Strong proficiency in Microsoft Office Suite and 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. Work Environment Full‑Time. 100% Remote (United States). Reliable, secure internet connection required. Must maintain licensure eligibility for assigned state contract. 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 and 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. Equal Opportunity Employer Comagine Health is an equal opportunity employer and is committed to creating a diverse, equitable, and inclusive workplace. Equal employment opportunity, including veterans and individuals with disabilities. #J-18808-Ljbffr Comagine Health