Clinical Review Nurse - Concurrent Review

Spectraforce Technologies; Austin (TX); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare company is seeking a Clinical Review Nurse to perform concurrent reviews and evaluate patient care. This remote position requires strong clinical knowledge and the ability to work with medical staff to ensure appropriate care delivery. Ideal candidates will have a nursing degree, relevant experience, and excellent communication skills. Join a dynamic team focused on improving patient outcomes and ensuring compliance with healthcare regulations.

Qualifications

• 2-4 years of related experience required.
• Must possess a TX RN License or Compact State RN license.

Responsibilities

• Perform concurrent reviews to determine member's overall health and care necessity.
• Collaborate with healthcare providers for medical determinations.

Skills

Communication

Documentation

Computer Skills

Education

Bachelor's degree in Nursing

Graduate from an Accredited School of Nursing

Tools

Microsoft

Excel

Job description

Job Title: Clinical Review Nurse - Concurrent Review

Job Location: Remote -TX

Job Duration: 06 Months (Contract to Hire?)

Shift: Monday-Friday (8am-5pm) CST



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:

LPN - Licensed Practical Nurse - State Licensure requiredPerforms 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

• Will need to complete authorization reviews within 24-hour TAT. The nurse is expected to work about 12-20 auths per day. They will get a mixture of new and concurrent reviews. The goal is to reach individual hourly weighted productivity of 2.49-3.21 in order to meet expectations. If the authorization doesn't meet medical necessity criteria, CRN should be sending to MD. Concurrent Review Referral Rate should be 30%-40%. CRN should also be completing any Enterprise Compliance courses timely within Centene University.


• The first day will consist of onboarding. They will meet with IT to log into VPN and Trucare. They will be saving links and job aids, meet with people leader and preceptor to go over expectations, processes, calendar, and they end up shadowing their preceptor for the remaining part of the day. They will go through a learning journey with corporate that usually begins later that week. They will have a training instructor and days are planned out for them. During this learning journey they will get information about Trucare Classic and how to review authorizations within Interqual. The last week of the learning journey will consist of them learning the Ambetter specific line of business. Throughout the learning journey they will have some shadow time, precepting time, and independent work.


• ***ICU or ER background experience, Utilization Management experience. They need to have strong computer, documentation, and communication skills. They will be toggling between different screens. They would need to catch on fast. Our Texas volume is high. If they have InterQual experience and know the Ambetter line of business that's a plus. They must possess a TX RN License or Compact State RN license.

Must haves: Microsoft and Excel

Nice to haves: ICU-ER experience**, UM Experience, CM Experience

Education/Certification	Required: RN	Preferred: BSN, ICU/ER experience
Licensure	Required: TX RN License or Compact State License	Preferred: n/a