Clinical - Clinical Review Nurse - Concurrent Review

Pyramid Consulting Healthcare; Dallas (TX); On-site; USD 50,000 - 54,000; Full time

Benefits offered by this job

Health insurance

401(k) plan

Paid sick leave

Job summary

Pyramid Consulting, Inc. is seeking an experienced Clinical Review Nurse for concurrent review in Dallas, TX. This is a 6+ month contract position onsite.

The role requires RN, MCO/Managed care, denials management, and at least 2 years of acute care experience. You will evaluate care, collaborate with Medical Affairs, and document findings.

Qualifications

• RN required with active state license.
• Experience with managed care organizations and denials.
• At least 2 years of acute care experience.
• Graduate from an accredited nursing program.

Responsibilities

• Perform concurrent reviews to determine appropriate care and setting.
• Analyze acuity, resource use, and discharge planning.
• Collaborate with Medical Affairs and Medical Directors.
• Document findings and discharge plans in health systems.
• Educate providers on utilization processes to ensure quality care.

Skills

RN

MCO experience

Denials management

Acute care

Education

RN degree (BSN or equivalent)

Job description

Immediate need for a talented Clinical - Clinical Review Nurse - Concurrent Review. This is a 06+months contract opportunity with long-term potential and is located in Dallas, TX(Onsite). Please review the job description below.

Job ID: 26-33363

Pay Range: $36/hr - $39/hour.

Employee benefits include, but are not limited to:

• health insurance (medical, dental, vision)
• 401(k) plan
• paid sick leave (depending on work location)

Key Responsibilities:

• Perform concurrent reviews of members to determine appropriate care and setting.
• Evaluate quality and continuity of care by analyzing acuity levels, resource consumption, and discharge planning.
• Collaborate with Medical Affairs and Medical Directors regarding member care.
• Document and maintain concurrent review findings and discharge plans in health management systems.
• Work with healthcare providers to approve medical determinations based on concurrent review findings.
• Educate providers on utilization processes to ensure high-quality care.
• Provide feedback to leadership on opportunities for improvement in care levels and medical necessity.
• Review members' transfer or discharge plans for timely transitions.
• Collaborate with care management for appropriate member referrals.
• Comply with all policies and standards.

Key Requirements and Technology Experience:

• RN Required
• MCO/Managed care experience required
• Denials Management experience required
• 2+ years of acute care experience.
• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• Knowledge of Medicare and Medicaid regulations (preferred).
• Familiarity with utilization management processes (preferred).

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.