Clinical Reviewer (RN) Qualified Intellectual Disabilities Pro

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 support and embrace remote work and offer opportunities to make a difference from anywhere in the U.S. An annual stipend helps you enhance your workspace. 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. Team member will serve as the QIDP (0.5 FTE) and as a nurse clinical reviewer (0.5 FTE). Key Responsibilities Apply Alabama Medicaid program criteria and guidelines to determine the medical necessity of health care services. Experience with Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). Complete reviews within timelines established by applicable state and federal requirements. Consult and forward to a Physician Advisor/Consulting Physician all cases where a medical necessity determination cannot be rendered. Work with administrative support, as appropriate. Identify customer needs and expectations and respond to them in a timely and effective manner. Anticipate and prevent delays or other adverse impacts to customers and inform them about the status of pending actions and inquiries. Attend Medicaid meetings, fair hearings, and hearings of legislative committees and interested governmental bodies, agencies, and officers, upon request. Education & Experience BA/BS in Nursing Active RN in 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 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. #J-18808-Ljbffr COMAGINE HEALTH