Clinical Reviewer

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.

We are seeking PRN Clinical Utilization Review Nurses (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 Washington D.C. This position will fill in for employees that are on leave or on PTO so weekend and evening work is expected. Expected work hours up to 19 hours per week.

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