Position Title: Clinical Review Nurse -Concurrent Review
Location: Remote, Compact Nursing License Required, Central Time Zone
Duration: 12 Months
Schedule: Friday-Tues, 2 pm-10 pm CST, 40 hours/week.
So, either five 8-hour shifts until 10 PM EST, Friday-Tues, OR four 10-hour shifts until 10 pm EST, Sat-Tues
PR: $35-45.00/HR
Key Responsibilities
Performs concurrent reviews of members 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
Education/Certification Required:
Licensure Required:
Years of experience required:
Disqualifiers:
Additional qualities to look for:
MCO experience, specifically with Medicaid, True Care Cloud experience is a bonus, experience working remote