Remote Concurrent Review Nurse

Job Description

Job Description

Job Title: Concurrent Review Nurse Job Description

The Concurrent Review Nurse plays a vital role in ensuring that members receive the appropriate level of care by conducting concurrent reviews, evaluating medical necessity, and contributing to discharge planning according to established care policies and guidelines.

• Conduct concurrent reviews of members to determine the appropriateness of care and setting, assessing overall health and care levels.
• Review and ensure the quality and continuity of care by analyzing acuity level, resource consumption, length of stay, and discharge planning.
• Collaborate with Medical Affairs and/or Medical Directors to discuss member care and provide necessary recommendations.
• Document and maintain findings, discharge plans, and actions taken in health management systems according to utilization management policies.
• Work closely with healthcare providers to approve medical determinations or provide recommendations based on concurrent review findings.
• Educate providers on utilization processes to ensure high-quality care delivery to members.
• Provide feedback to leadership on improving care levels and medical necessity based on clinical policies.
• Ensure timely transitions of care between levels of care and facilities by reviewing transfer or discharge plans.
• Collaborate with care management teams on appropriate member referrals.
• Perform other duties as assigned while complying with all policies and standards.

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
• 2-4 years of related experience, including 2+ years of acute care experience.
• Clinical knowledge to assess overall health and treatment needs.
• Knowledge of Medicare and Medicaid regulations.
• Understanding of utilization management processes.
• State Licensure as a Licensed Practical Nurse or RN license for Health Net of California.
• Ability to apply InterQual, MCG, and established utilization management criteria to support review decisions.

• Experience with conducting concurrent reviews of inpatient hospital and post-acute care cases.
• Proficiency in evaluating clinical documentation, treatment plans, and resource utilization.
• Experience with documenting findings in TruCare Classic and TruCare Cloud.
• Ability to facilitate care transitions and provide recommendations on medical necessity.
• Skills in educating providers on utilization management processes and clinical guidelines.
• Problem-solving and triage skills related to utilization review cases.
• Compliance with organizational, state, federal, Medicare, and Medicaid regulations.

The position requires working within a healthcare setting, collaborating with a diverse team of healthcare professionals, including physicians, providers, and care management teams. The role involves utilizing technologies such as TruCare Classic and TruCare Cloud to document and support review decisions. The work environment supports professional growth and collaboration, adhering to high standards of care and regulatory compliance.

This is a Contract to Hire position based out of Texas City, TX.

The pay range for this position is $38.00 - $42.00/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

This is a fully remote position.

This position is anticipated to close on Oct 8, 2026.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 20,000 consultants and 5,000 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. We are proud to be an Engineering News-Record (ENR) Top 500 Design Firm for our engineering design services and a ClearlyRated Best of Staffing® winner for both client and talent service.

The company is an equal opportunity employer and will consider all applications withoutregard to race, sex, age, color, religion, national origin, veteran status, disability,sexual orientation, gender identity, genetic information or any characteristic protectedby law.

If you would like to request a reasonable accommodation, such as the modification oradjustment of the job application process or interviewing process due to a disability,please email View email address on ziprecruiter.com for other accommodation options.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in thecity and county of San Francisco, we will consider for employment qualified applicantswith arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as acondition of employment or continued employment. An employer who violates this lawshall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process,including sourcing, screening, and evaluating candidates. AI helps assess applicationsand qualifications, but final decisions are made by our hiring team. By applying, youacknowledge and agree that your application may be reviewed using AI tools.