Clinical Review Nurse - Concurrent Review

Position Title : Clinical Review Nurse - Concurrent Review Work Location : Remote - Central, Mountain or Pacific preferred Assignment Duration : 6 months (temp to hire) Work Arrangement: Remote Position Summary : Workload review for census management: Review assigned cases, prioritize new requests, cases due for continued-stay review, time-sensitive discharges, and cases approaching regulatory or internal turnaround-time requirements. Identify high-risk or complex members requiring early escalation. Key Responsibilities: Workload review for census management: Review assigned cases, prioritize new requests, cases due for continued-stay review, time-sensitive discharges, and cases approaching regulatory or internal turnaround-time requirements. Identify high-risk or complex members requiring early escalation. Clinical Review: Accessing medical management platforms for UM clinical medical necessity reviews for inpatient; Review the member's current clinical status, level of care, functional needs, treatment plan, progress, and discharge barriers. Apply the appropriate clinical criteria and benefit requirements to determine whether the requested level of care remains medically appropriate. Authorization documentation: Complete authorization activities within required timeframes and document the clinical rationale, criteria applied, communications, decisions, and next review date clearly and accurately in the medical management system. Level 2 escalation: Identify cases that do not clearly meet criteria, have significant clinical complexity, or require additional medical judgment. Prepare the case for medical director review and communicate relevant clinical information according to templated formats. Post-acute coordination: Evaluate appropriateness for lower level of care such as SNF, inpatient rehabilitation, LTACH, home health, or other post-acute care. Work with facilities, providers, case management, and other internal partners to obtain missing clinical information and support timely transitions of care. Interdisciplinary Collaboration: Participate in rounds, huddles, or case discussions to address complex cases, avoidable delays, barriers to discharge, readmission risk, and opportunities to transition members to the most appropriate setting. Reassess active cases as new clinical information becomes available. Monitor progress toward discharge goals and identify members who may be remaining at a higher level of care longer than clinically necessary. Quality and QAI support: Recognize patterns such as prolonged stays, repeat admissions, authorization delays, inconsistent provider practices, or gaps in transitions of care. Escalate trends that may represent opportunities for quality or process improvement Candidate Requirements Education/Certification Required: Graduate from an accredited school of nursing or bachelor's degree in nursing and 2 - 4 years of related experience Preferred: Compact licensure will work OR willing to acquire a required state license Licensure Required: RN - State Licensure Preferred: Experience with Medical necessity tools such as InterQual or MCG Years of experience required: 2+ years of acute care experience required 2 - 4 years of related experience Disqualifiers: No license. No direct care experience in an acute inpatient setting. Additional qualities to look for: Top 3 must-have hard skills stack-ranked by importance 1 Strong Clinical Judgment and Critical Thinking Requires analyzing complex clinical situations and applying UM criteria and guidelines Agile, ability to manage competing priorities 2 Communication & Care Coordination * Clear, concise communication with providers, care teams, and insurance representatives * Ability to advocate for appropriate care while maintaining positive provider relationships * Skilled at documenting clinical findings and review decisions accurately and timely 3 Knowledge of Regulations, Policies, and Payer Requirements * Familiarity with CMS guidelines, payer policies, authorization processes, and compliance standards * Ability to apply regulatory knowledge when making review decisions * Ensures consistent adherence to organizational and industry guidelines