Clinical Reviewer RN - Alabama
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 respond 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
Required Skills & Competencies
Experience With Performing PA reviews
Long-term care including nursing home, ICF/IID, swing bed, PEC, and inpatient psychiatric facilities
Provider relations
Reporting
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.