Clinical Reviewer

Company: Comagine Health
Employment Type: PRN

Comagine Health is seeking a Clinical Reviewer - On-Call - PRN (less than 20 hours per week) to assess the medical necessity, quality, and appropriateness of healthcare services. This role conducts prospective, concurrent, and retrospective utilization management reviews to support high-quality, cost-effective care while ensuring compliance with evidence-based guidelines, regulatory requirements, and organizational policies.

• Conduct prospective (pre-authorization), concurrent/continued stay, and retrospective utilization management reviews to ensure appropriate use of healthcare resources.

• Conduct compliance and/or quality audits of medical records/patient charts for accuracy, completeness, and adherence to established standards.

• Evaluate requests for healthcare services using clinical review criteria, organizational policies, regulatory requirements, and evidence-based guidelines to determine medical necessity and appropriateness.

• Perform compliance and quality audits of medical records and patient charts for accuracy, completeness, and adherence to established standards.

• Consult with physician or practitioner consultants when reviews do not meet clinical criteria and refer cases to other clinicians as appropriate.

• Provide day-to-day oversight and monitoring of non-clinical staff performing non-clinical support activities, as applicable, and offer performance feedback to the supervisor.

Education

• Bachelor's degree (BA/BS) required

• BS in Nursing

Licensure

• Current, active, unrestricted clinical licensure required

Experience

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

• 1 year of utilization review or medical management experience preferred

• Intermediate communication skills

• Intermediate interpersonal and relationship-building skills

• Foundational professionalism and integrity

• Foundational work ethic and reliability

• Intermediate clinical knowledge

At Comagine Health, we partner with healthcare organizations to improve outcomes and optimize care delivery. This role offers the opportunity to apply your clinical expertise in a broader population-health setting while contributing to meaningful, quality-driven healthcare decisions.