Clinical - Clinical Review Nurse - Concurrent Review - J00933

Will work within TruCare Cloud Candidate Requirements Education/Certification Required: Required: Highschool Diploma, Nursing Degree- Associates or Above Preferred: Licensure Required: Compact Nursing License-RN, LPN, LVN. 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.

Job Profile Summary
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.

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.

License/Certification:
LPN - Licensed Practical Nurse - State Licensure required
For Health Net of California: RN license required

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

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

============

Job Profile Summary 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. 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. License/Certification: Compact Nursing Licensure Needed for either LVN/LPN or RN LPN - Licensed Practical Nurse - State Licensure required RN- Registered Nurse- State Licensure required For Health Net of California: RN license required 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
Story Behind the Need
What is the purpose of this team? Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?		Needing 1 nurse to join the team to process denial letters for Medicaid Behavioral and Physical Health codes that will need prior authorization. Experience with Co-Pilot a plus Experience with Trucare Cloud a plus
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?		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
Candidate Requirements
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
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations		Projected Manager Candidate Review Date:			1-2 days post shortlisting
		Type of Interviews:			Teams cameras on
		Required Testing or Assessment (by Vendor):			Computer literacy knowledge