Clinical - Clinical Review Nurse - Concurrent Review - J00933

Spectraforce Technologies, Inc.; Raleigh (NC); Remote; USD 55,000 - 77,000; Full time

Job summary

Spectraforce Technologies, Inc. is seeking a Clinical Review Nurse - Concurrent Review for a remote role with EST preference. The position involves assessing patient health, determining medical necessity, and contributing to discharge planning under care policies.

Requires an accredited nursing degree (RN or BSN), RN or LPN licensure, and 2–4 years of acute care or UM experience. NVIDIA, remote work, and rotated holiday coverage may apply.

Qualifications

• Accredited School of Nursing or bachelor’s degree in nursing.
• 2–4 years of related experience in nursing, UM or managed care preferred.
• RN or LPN licensure required; active licensure.

Responsibilities

• Performs concurrent reviews to determine appropriate care and level of care.
• Reviews quality and continuity of care including discharge planning.
• Collaborates with Medical Affairs/Directors as needed.
• Documents findings and actions in health management systems per policies.
• Interacts with healthcare providers to approve determinations or provide recommendations.
• Educates providers on utilization processes to ensure high‑quality care.
• Provides feedback to leadership on opportunities to improve care and NM.
• Reviews transfer or discharge plans to ensure timely transitions.
• Collaborates with care management on referrals as appropriate.
• Performs other duties as assigned and complies with policies.

Skills

Clinical knowledge

Medicare/Medicaid regulations

Utilization management

Education

Nursing degree (RN or BSN)

Job description

Position Title

Clinical Review Nurse - Concurrent Review

Work Location

Remote, Source from EST preferred but will consider CST

Assignment Duration

6 Months

Work Schedule

Eastern 8-5 with expected weekend and holiday coverage based off the team needs, but this can change. Also, working holidays are expected under a rotated schedule.

Work Arrangement

Remote

Position Summary

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.

Key Responsibilities

• 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.

Qualification & Experience

Candidate Requirements

Education/Certification

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

Preferred: Accredited School of Nursing or bachelor's degree in nursing

Licensure

Required: LPN/RN

Preferred: LPN/RN

Years of experience required

2 - 4 years of related experience.

2+ years of acute care experience required/UM or managed care exp preferred

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.