Clinical - Clinical Review Nurse - Concurrent Review - J00933

Job Title: Clinical Review Nurse - Concurrent Review

Location: Remote

Duration: 12 months

XXXX: XXXXXXXXXXX/hr. on w2

Scheule: 10am -7pm CST

Tuesday Saturday with rotating holidays Or
Sunday- Thursday with rotating holidays

Position Purpose:

• Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines.
• Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
• Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member.
• Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered.
• Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines.
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
• Assists with providing education to providers on utilization processes to ensure high-quality appropriate care to members.
• Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines.
• Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collaborates with care management on referral of members as appropriate.
• Performs other duties as assigned.
• Complies with all policies and standard.
• Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
  
  
  
  

Typical Day in the Role :

• Process denial management systems (claims, correspondence platform, appeals tracking).

Performance Expectations/Metrics:

• Prioritize Tasks: Review pending denial letters, escalations, and compliance deadlines.
• Check Emails & Updates: Look for policy changes, payer updates, or internal communications that could affect denial handling.
• Once fully trained, at least 2.6 denial letters per hour starting point is 5 10 letters per week when ramping before.

Education/Certification:

Required:

• Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 4 years of related experience.
• Registered Nurse Licensed Practical Nurse or compact license to support LA

Preferred:

• Registered Nurse licensure

Licensure:

Required: Compact Nurse Licensure

Years of experience required:

• 1-2 years of experience

Disqualifiers:

• Cannot work shift times or not in time zone.

Additional qualities to look for:

• UM background can be teachable but would be preferred
• Denials experience very beneficial
• Medical Terminology

Top 3 must-have hard skills stack-ranked by importance:

1. Multi-tasking
2. Adapt to change well
3. Attention to detail