Clinical Reviewer New Mexico

Category

Care Management

Job Location

Remote

Tracking Code

134750

Industry

Select Industry

Job Level

Mid Career

Position Type

Full-Time/Regular

Years of Experience

Not Applicable

Who is Comagine Health?

Comagine Health is a non-profit consulting firm that seeks to improve health and to increase the effectiveness and quality of health care. As a recognized Quality Improvement Organization (QIO), we support providers, plans, purchasers, and consumers, and offer services to state and federal agencies and others to help them better manage health care under the existing system and to assess, plan for and implement broader system transformation. We collaborate with academic, government, and nonprofit partners on initiatives funded by NIH, CDC, AHRQ, BJA, SAMHSA, and others. In short, we are changing healthcare at a fundamental level.

Purpose

Assess the medical necessity and quality of healthcare services by conducting prospective, concurrent, and retrospective utilization management reviews.

Education
BA/BS in a nursing field

Years of Experience in Related Field
Required

3 years of clinical (direct patient care) experience
Preferred + 1 year of utilization Review experience

Experience with developmentally disabled patients

Licensure
Required
Current, active, unrestricted clinical licensure as required by the state of New Mexico.  

Specialized Knowledge, Skills, and Abilities and/or Competencies

• Strong MS Office Suite proficiency and familiarity with database software programs
• Strong organizational skills
• Excellent oral and written communications skills
• Excellent interpersonal and problem-solving skills
• Ability to organize and coordinate multiple simultaneous tasks in a team environment
• InterQual Criteria experience

Typical Job Duties and Responsibilities

• Apply clinical review criteria, organizational policies, guidelines, and screens to determine the medical necessity of health care services.
• Consult with physician/practitioner consultants when reviews fail clinical review criteria, guidelines, and screens.
• Refer cases to others when collaboration as required.
• Refer cases to management as needed.
• Provide clinical and/or review process subject matter expertise, respond to customers questions or concerns.
• If needed, conduct an outreach to consultants, community support coordinators, case managers, and/or providers for required additional information
• May perform quality assurance audits and other program support, as assigned by supervisor.
• Participate in peer reviews
• Other duties as assigned

Compensation Range: $65k – $85k.