Clinical Review Nurse - Concurrent Review - J00933

Candidate Requirements Education/Certification Required: Accredited School of Nursing or Bachelor s degree in Nursing Preferred: Licensure Required: LPN/RN Preferred: Years of experience required: 2 4 years of related experience. Description: Job Profile Summary For a UM CCR team, our primary focus is delivering timely, accurate, and clinically appropriate authorization reviews while maintaining compliance, quality, and positive member outcomes.

Location: 100% Remote, Source from EST preferred but will consider CST

SHIFT: Eastern 8-5 with expected weekend and holiday coverage based off the team needs. This is usually every 4-5 th weekend but this can change. Also working holidays are expected under a rotated schedule.

Duration: 6 months

Target start Date: 11/9/2026

Description: Job Profile Summary

• For a UM CCR team, our primary focus is delivering timely, accurate, and clinically appropriate authorization reviews while maintaining compliance, quality, and positive member outcomes. Based on our UM program requirements and CCR operational expectations, several key initiatives drive success.
• 14 per day on average, 2.12 per hour. Weighted productivity about 95% along with audit scores above 95%
• 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.
• Performs other duties as assigned.
• Comply with all policies and standards.

Candidate Requirements
Education/Certification	Required: Accredited School of Nursing or Bachelor s degree in Nursing			Preferred:
Licensure	Required: LPN/RN			Preferred:
Years of experience required: 2 4 years of related experience. 2+ years of acute care experience required/UM or managed care exp preferred Disqualifiers: No active LPN/RN, No acute care experience Additional qualities to look for:
Top 3 must-have hard skills stack-ranked by importance		1	Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
		2	Knowledge of Medicare and Medicaid regulations preferred.
		3	Knowledge of utilization management processes preferred.