Clinical Review Nurse - Concurrent Review

Summary:

• Work Mode: 100% Remote - Prefer candidates in Central, Mountain, or Pacific time zones
• Duration: 6 months, possible extension
• Shift: 8-hour day, Mon – Fri: business hours to cover 4 US time zones. Start times from 8am ET. End time to 5pm PT. Weekends/Holidays: Scheduled rotation.

Responsibilities:

• Workload review for census management: Review assigned cases, prioritize new requests, cases due for continued-stay review, time-sensitive discharges, and cases approaching regulatory or internal turnaround-time requirements. Identify high-risk or complex members requiring early escalation.
• Clinical Review: Access medical management platforms for UM clinical medical necessity reviews for inpatient; review the member’s current clinical status, level of care, functional needs, treatment plan, progress, and discharge barriers.
• Authorization documentation: Complete authorization activities within required timeframes and document the clinical rationale, criteria applied, communications, decisions, and next review date clearly and accurately in the medical management system.
• Level 2 escalation: Identify cases that do not clearly meet criteria, have significant clinical complexity, or require additional medical judgment. Prepare the case for medical director review and communicate relevant clinical information according to templated formats.
• Post-acute coordination: Evaluate appropriateness for a lower level of care such as SNF, inpatient rehabilitation, LTACH, home health, or other post-acute care. Work with facilities, providers, case management, and other internal partners to obtain missing clinical information and support timely transitions of care.
• Interdisciplinary Collaboration: Participate in rounds, huddles, or case discussions to address complex cases, avoidable delays, barriers to discharge, readmission risk, and opportunities to transition members to the most appropriate setting.
• Quality and QAI support: Recognize patterns such as prolonged stays, repeat admissions, authorization delays, inconsistent provider practices, or gaps in transitions of care. Escalate trends that may represent opportunities for quality or process improvement.
• End of day reconciliation: Ensure reviews due that day are completed, outstanding clinical information is followed up on, urgent cases are handed off appropriately, and documentation accurately reflects the current status and next steps.

Requirements:

• Education/Certification: Graduate from an accredited school of nursing or bachelor’s degree in nursing; RN - State Licensure required.
• Experience: Minimum 2 years of acute care experience required; 2 years of related experience.
• Disqualifiers: No license. No direct care experience in an acute inpatient setting.

Preferred Skills:

• Strong Clinical Judgment and Critical Thinking: Requires analyzing complex clinical situations and applying UM criteria and guidelines.
• Communication & Care Coordination: Clear, concise communication with providers, care teams, and insurance representatives.
• Knowledge of Regulations, Policies, and Payer Requirements: Familiarity with CMS guidelines, payer policies, authorization processes, and compliance standards.