Clinical Reviewer
Comagine Health
Job Overview
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Job Description
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 go beyond merely providing a remote work option; we support and embrace it. We offer opportunities to make a difference from anywhere in the U.S. and enjoy better work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs.
Benefits
We believe in an environment that allows you to thrive both personally and professionally. That’s why we offer benefits that include:
- 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 Reviewer (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
- Must meet New Mexico state and contract-specific requirements
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
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.
Key skills/competency
- Clinical Review
- Utilization Management
- InterQual
- Medical Necessity
- RN License
- Healthcare Quality
- Patient Outcomes
- Regulatory Compliance
- Documentation
- Communication Skills
How to Get Hired at Comagine Health
- Research Comagine Health's mission: Study their commitment to healthcare quality improvement and non-profit values.
- Customize your resume: Highlight extensive utilization review, InterQual, and direct patient care experience.
- Emphasize remote work readiness: Showcase your proven ability to manage priorities and communicate effectively in remote settings.
- Prepare for clinical scenario questions: Be ready to discuss medical necessity criteria, regulatory compliance, and complex case resolutions.
- Demonstrate collaborative problem-solving: Share examples of working with internal and external stakeholders to achieve positive patient outcomes.
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