Job Title: Clinical Review Nurse - Concurrent Review
Location: Remote
Payrate: $40-45/hr on W2
Duration: 12 Months (Possibility to extend)
Schedule: Mon-Friday, 11AM to 8pm CST; Weekends and Holidays on a rotation basis based on business needs-(Weekends are more of an if needed basis but holidays are rotated). Possible 10-Hour, 4 day work week if aligns with candidate)
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.
Typical Day in the Role:
- Denial Letters for TX Medicaid Behavioral Health Codes
- Daily Points are the measurement of production
- Must meet 100% production after training period
- Remote Work, Various Schedules Available
- Will work within TruCare Cloud
License/Certification:
- Compact Nursing Licensure RN
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
Education/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.
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:
- Ability to complete work independently and with minimal supervision after training.
- Team player
- Great organizational skills
Good to have:
- Experience with Co-Pilot a plus
- Experience with Trucare Cloud a plus