Clinical Review Nurse - Concurrent Review

Position Title: Clinical Review Nurse - Concurrent Review

Work Location: Remote (Compact Nursing License Required, Central Time Zone)

Assignment Duration: 12 months (Possibility to extend or convert)

Work Schedule: Friday-Tues, 2 pm-10 pm CST, 40 hours/week.

Either five 8-hour shifts until 10 PM EST Friday-Tues,

OR four 10-hour shifts until 10 PM EST Sat-Tues

Work Arrangement: Remote

Position Summary :

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.

Key Responsibilities :

* Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care

* 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 standards

Qualification & Experience :

* Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. 2+ years of acute care experience required.

* 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. Education/Certification
Required: Required: Highschool Diploma, Nursing Degree- Associates or Above
Preferred:

Licensure
Required: Compact Nursing License-RN, LPN, LVN.
Preferred:

Years of experience required: 1+ years,

Disqualifiers: Inability to work possible weekend hours and holidays on a rotation basis as applicable or needed by business needs

Additional qualities to look for: MCO experience, specifically with Medicaid, True Care Cloud experience is a bonus, experience working remote

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

1
Ability to complete work independently and with minimal supervision after training.

2
Team player

3
Great organizational skills