Clinical Review Nurse (Concurrent Review)

Responsibilities:

• Perform concurrent reviews of members for appropriate care and setting to determine overall health and appropriate level of care.
• Review quality and continuity of care by assessing acuity level, resource consumption, length of stay, and discharge planning of members.
• Collaborate with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered.
• Collect, document, and maintain concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines.
• Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
• Assist with providing education to providers on utilization processes to ensure high-quality appropriate care to members.
• Provide feedback to leadership on opportunities to improve appropriate level of care and medical necessity based on clinical policies and guidelines.
• Review member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collaborate with care management on referral of members as appropriate.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements:

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• Minimum 2 years of acute care experience required.
• LPN - Licensed Practical Nurse - State Licensure required.
• For Health Net of California: RN license required.

Preferred Skills:

• Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care.
• Knowledge of Medicare and Medicaid regulations.
• Knowledge of utilization management processes.