Clinical Reviewer PRN

The PRN/part-time position requires availability for at least two four-hour shifts per week. The hours are not limited. Weekend hours are available.

Clinical Reviewers work from an electronic review queue to evaluate applicable authorization requests and supporting medical records for medical necessity and appropriateness. They apply workers’ compensation treatment guidelines, clinical criteria, and organizational policies to approve cases when appropriate or refer cases requiring additional review to Medical Affairs and physician reviewers. Reviewers research applicable treatment guidelines, document decisions and supporting rationale. They also manage pended cases, obtain additional information through providers or the claim system, and communicate with clinics. Clinical Reviewers collaborate with physician advisors, providers, and internal teams to support accurate, timely, and well-documented review decisions.

If you’re ready to put your clinical expertise and critical thinking skills to work in a role focused on thoughtful, evidence-based review, we encourage you to apply and learn more about joining our team.

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:

Position Overview

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 is a PRN, remote position supports high-quality, appropriate, and cost-effective care while ensuring compliance with clinical criteria, organizational policies, and contract requirements specific to Alaska.

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

• Minimum of 3 years of direct patient care (clinical) experience

Licensure

• Current, active, unrestricted RN license

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

• PRN
• 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.

Originally posted on Himalayas