Clinical Review Nurse - Concurrent Review

Summary:

• Work Mode: Remote
• Duration: 12 months with possible extension
• Schedule: Mon-Friday, 11AM to 8pm CST; Weekends and Holidays on a rotation basis based on business needs. Possible 10-Hour, 4 day work week if aligns with candidate.

Responsibilities:

• Perform concurrent reviews of members for appropriate care and setting to determine overall health and appropriate level of care.
• Review quality and continuity of care by evaluating acuity level, resource consumption, length of stay, and discharge planning of members.
• Collaborate with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered.
• Collect, document, and maintain concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines.
• Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
• Assist with providing education to providers on utilization processes to ensure high-quality appropriate care to members.
• Provide feedback to leadership on opportunities to improve appropriate level of care and medical necessity based on clinical policies and guidelines.
• Review member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collaborate with care management on referral of members as appropriate.
• Perform other duties as assigned.

Requirements:

• Graduate from an Accredited School of Nursing or a Bachelor’s degree in Nursing.
• Minimum 2 years of acute care experience required.
• Compact Nursing License-RN, LPN, LVN required.
• Ability to work possible weekend hours and holidays on a rotation basis as needed by business needs.

Preferred Skills:

• Clinical knowledge and ability to determine the overall health of members including treatment needs and appropriate level of care.
• Knowledge of Medicare and Medicaid regulations.
• Knowledge of utilization management processes.
• MCO experience, specifically with Medicaid.
• Experience working remotely.
• True Care Cloud experience is a bonus.
• Ability to complete work independently and with minimal supervision after training.
• Team player.
• Great organizational skills.