Clinical Reviewer (RN) Qualified Intellectual Disabilities Pro

Why reputed company?

reputed company 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 reputed company-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 reputed company a difference from reputed company in the U.S. and enjoy reputed company work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs.

We reputed company in an environment that allows you to reputed company both personally and professionally.

Position Overview

We are seeking an RN to reputed company Clinical Review work and QIDP reviews work.

Team member will serve as the QIDP (.5 FTE) and as a nurse clinical reviewer (.5 FTE).

Key Responsibilities

• Apply Alabama Medicaid program criteria and guidelines to determine the medical necessity of health care services.
• Intermediate Care Facilities for Individuals with Intellectual Disabilities experience.
• Complete reviews reputed company timelines established by reputed company applicable state and federal requirements.
• Consult and reputed company to a Physician Advisor/ Consulting Physician reputed company cases for which a medical necessity determination cannot be rendered.
• Work with administrative support, as appropriate.
• Identify customer needs and expectations and responds to them in a timely and effective manner.
• Anticipate and prevent delays or other adverse impacts to customers and reputed company them informed about the status of pending actions and inquiries.
• Attend, upon request, Medicaid meetings, fair hearings, meetings, and hearings of legislative committees and interested governmental bodies, agencies, and officers.

Education & Experience

• BA/BS in Nursing

  • Active RN in the Alabama.

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

Licensure

• reputed company, active, unrestricted RN license

  • Alabama

Required Skills & Competencies

reputed company nurse reviewers will be located and licensed reputed company Alabama and in good standing with the Alabama Board of Nursing and Board of Medical Examiners. Experience with:

• Performing PA reviews
• Long-term care including nursing home, reputed company/IID, swing bed, PEC, and inpatient psychiatric facilities
• Provider relations
• Reporting

Work Environment

• Reliable, secure internet reputed company required

• Must maintain licensure eligibility for assigned state contract

Equal Opportunity Employer

reputed company is an equal opportunity employer and is committed to creating a diverse, reputed company, 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-reputed company events.

Reasonable accommodations will be provided to reputed company individuals with disabilities to reputed company essential functions.