Concurrent Review Nurse

Under the general supervision of the Director of Health Services, the Concurrent Review Nurse is responsible for ensuring the delivery of medically necessary, high-quality, and cost-effective care. This is achieved through the review of inpatient admissions, outpatient precertification, and prior authorization requests, using established medical policies, evidence-based guidelines, and managed care standards. Essential Duties and Responsibilities Lead, train, and support both clinical and non-clinical staff in accordance with Leon Health's policies and procedures to ensure efficient and effective performance. Monitor and respond to incoming calls and written inquiries from members, providers, and internal departments. Oversee the quality, accuracy, and timeliness of prior authorization reviews and ensure appropriate prioritization. Enter service requests and determination data into the appropriate systems in compliance with regulatory requirements and organizational policies. Review clinical documentation for precertification and concurrent (ongoing) reviews. Perform on-site and/or telephonic reviews to determine the appropriateness of inpatient and outpatient care settings, using medical policies, CMS guidelines, and industry standards. Conduct medical and behavioral health (BH) reviews for pre- and post-service authorization requests. Issue authorizations for inpatient admissions, outpatient services, and post-service requests to providers, facilities, and members as applicable. Refer complex cases to a Medical Director or Behavioral Health Practitioner when additional clinical evaluation is required. Ensure all documentation is complete, accurate, and clearly supports authorization decisions. Process denial determinations in compliance with regulatory standards and internal policies. Maintain up-to-date census reports, daily notes, and authorization records, including tracking admissions and discharges. Collaborate with healthcare providers to obtain necessary clinical documentation for medical necessity determinations. Work with providers to proactively identify discharge needs and assist in care planning. Facilitate smooth care transitions across the healthcare continuum by coordinating with facilities and the Care Management team. Education Bachelor's degree in Nursing required Experience Minimum of two (2) years of experience in clinical review or utilization management Language Skills Bilingual in English and Spanish (required) #J-18808-Ljbffr Leon Medical Center