Clinical - Clinical Review Nurse - Concurrent Review

Pacer Group; Texas; Remote; USD 10,000 - 60,000; Full time

Job summary

A leading healthcare company is seeking a Clinical Review Nurse for a remote position in Texas. The role involves performing concurrent reviews to evaluate patient care, ensuring medical necessity, and collaborating with healthcare providers. Candidates must have a nursing degree and RN licensure, with strong multitasking and clinical skills preferred.

Qualifications

• Requires RN licensure in Texas.
• Clinical knowledge to determine overall health and treatment needs.
• Knowledge of Medicare and Medicaid regulations preferred.

Responsibilities

• Performs concurrent reviews to determine overall health and appropriate level of care.
• Works with Medical Affairs and healthcare providers to approve medical determinations.
• Documents concurrent review findings and discharge plans.

Skills

Multitasking

Fast learner

Positive attitude

Computer savvy

Education

Graduate from an Accredited School of Nursing

Bachelor's degree in Nursing

Job description

Title : Clinical Review Nurse Concurrent Review

Location : Remote - TX

Duration : 6 months

Shift : 1st

Pay rate : $40-45.00 / hr

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.

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 :

RN- Registered Nurse - State Licensure required.

Job 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.

Must haves :

Multitasking, fast learner, positive, and be computer savvy.

Nice to haves :

Flexible, Ambetter knowledge

Less than 2 years of nursing experience, no LPNs.

Education / Certification

Required : Graduate from an Accredited School of Nursing or bachelor's degree in nursing

Licensure

Required : Texas RN

Create a job alert for this search