Clinical Reviewer New Mexico LinkedIn Twitter Email Message Share Category Care Management Job Location Nationwide Tracking Code 134719 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 national, nonprofit, health care consulting firm. We work collaboratively with patients, providers, payers, and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system. As a trusted, neutral party, we work in our communities to address key, complex health, and health care delivery problems. In all our engagements and initiatives, we draw upon our expertise in quality improvement, care management, health information technology, analytics, and research. We invite our partners and communities to work with us to improve health and redesign the health care delivery system. This is a fully remote position within the United States. Candidates with a Mountain Time Zone location will be considered 1st. Must have an active RN license. What you'll be doing for us: Apply clinical review criteria, 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 other professionals internally, including medical affairs consultation, as well as to customers and other appropriate external sources when indicated. Provide clinical and/or review process subject matter expertise; manage complex reviews, respond to customer requests or complaints; monitor and report pertinent observations of clinical performance. Provide initial clinical orientation to new employees as well as ongoing clinical mentoring and support for clinical review staff. Collaborate with the clients to provide clinical expertise on complex cases and or process clarification. Collaborate with Medical Affairs for complex case review and clinical topics. May perform quality assurance audits and program support as assigned. Report HIPAA and or PHI violations in the appropriate Freshservice database As appropriate, provide daily oversight and monitoring of non-clinical staff during their performance of non-clinical support activities; also provide the supervisor with input regarding employees' performance of these activities. Provide clinical and/or review process subject matter expertise; respond to customer questions or concerns. May perform quality assurance audits and other program support, as assigned. Compensation Range: 75k - 90k. We consider the location cost of labor with offers in conjunction with experience. Required Skills: What would make you a strong fit for our role: Computer skills, InterQual criteria experience Two years + of experience and skills in work processing, familiar with database software programs ( Microsoft Office). Basis spread sheet and presentation software Applications. Excellent oral and written communication skills Excellent interpersonal and problem-solving skills Excellent critical thinking skills and the ability to multitask Ability to organize and coordinate multiple simultaneous tasks in a team environment. Ability to conduct an assessment including identifying strengths and needs, life domain functionals, risk, cultural factors, behavioral and emotional needs; assess trauma and substance sue, health and safety risks to self or others, gathering histories of mental and physical health ,substance use, past mental health services, assessing care giver resources and needs, social and work relationships; community based person centered plan review experience, community based elderly persons with disabili