Clinical Reviewer

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Remote, US

13 days ago Requisition

Salary Range: $75,000.00 To $88,000.00 Annually

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.

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
• Paid parental leave.
• And much more!

We are seeking a Clinical Utilization Review Nurse (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
.

Conduct prospective, concurrent, and retrospective utilization management reviews

Apply clinical review criteria
, organizational policies, guidelines, and screening tools (
Inter Qual
)

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

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

Current, active, unrestricted RN license

Must meet New Mexico state and contract-specific requirements

Experience with
Inter Qual 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

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.

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.