Position Title: Clinical Review Nurse - Concurrent Review
Location: Remote- Georgia
Duration: 6 Months
Schedule: 7:00 AM 6:00 PM EST, Sunday Wednesday or Wednesday Saturday. Min OT when needed.
Pay Range: $40.00/hour - $45.00/hour
Overview:
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.
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
- Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and
- guidelines to emergent/urgent and continued stay reviews.
- Performs other duties as assigned. PERFORMANCE EXPECTATIONS: 95% weighted productivity, 2.1 reviews per hour (14 per day), 90% audit scores and 100% TAT.
Qualification:
- Graduate from an Accredited School of Nursing
- Nursing License with state of Georgia or Compact licensure.
- 2+ years of acute care experience required.
- Concurrent Review Utilization Management experience in a Medicaid/Marketplace health plan.
- Experience with InterQual.
- Knowledge of healthcare and managed care.
- Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay review.