Note: The job is a remote job and is open to candidates in USA. Comagine Health is a national, mission-driven, nonprofit organization focused on healthcare quality consulting and improvement services. They are seeking Clinical Utilization Review Nurses (RN) based in Alabama to assess the medical necessity and quality of healthcare services through utilization management reviews.

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 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

Skills

• BA/BS in Nursing
• Active RN in Alabama
• Minimum of 3 years of direct patient care (clinical) experience
• Current, active, unrestricted RN license in Alabama
• 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
• Experience With Long-term care including nursing home, ICF/IID, swing bed, PEC, and inpatient psychiatric facilities
• Experience With Provider relations
• Experience With Reporting
• Reliable, secure internet connection required
• Must maintain licensure eligibility for assigned state contract

Benefits

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

Company Overview