Clinical Review Nurse - Concurrent Review - J00933

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. 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.

Description: 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

Custom Fields:
Name: Shortlisting Date
Value: None

Name: Which Health Plan, programs or functions will this work support?
Value: WellCare of KY

Name: Field Worker
Value: No