Clinical Reviewer (RN) Qualified Intellectual Disabilities Pro

Position Overview

We are seeking an RN to perform Clinical Review work and QIDP reviews work. The 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.
• 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.
• 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

• 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

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.
• Sometimes requires 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.