Clinical Review Nurse - Concurrent Review

Spectraforce Technologies, Inc.; Charleston (SC); Remote; USD 65,000 - 90,000; Full time

Job summary

Spectraforce Technologies, Inc. is seeking a Clinical Review Nurse for remote concurrent review responsibilities. The role assesses member health status, medical necessity, and appropriate care levels, contributing to discharge planning within care policies and guidelines.

Ideal candidates have 2–4 years of related experience (2+ years acute care UM or managed care preferred), nursing licensure, and a nursing degree. Remote work with EST preferred; CST considered.

Qualifications

• Accredited School of Nursing or Bachelor's degree in Nursing is required.
• Active LPN/RN licensure is required.
• 2–4 years of related experience; 2+ years acute care UM or managed care experience preferred.

Responsibilities

• Perform concurrent reviews to determine appropriate care level and health status.
• Review acuity, resource use, length of stay, and discharge planning.
• Collaborate with Medical Affairs/Medical Directors on member care discussions.
• Document concurrent review findings and discharge plans in health management systems.
• Coordinate with providers to approve determinations or provide recommendations based on findings.
• Educate providers on utilization processes to ensure appropriate care.
• Provide feedback to leadership on opportunities to improve care and medical necessity.
• Review transfer/discharge plans to ensure timely care transitions.
• Collaborate with care management on member referrals.
• Perform other duties as assigned and comply with policies and standards.

Skills

Clinical knowledge

UM processes

Medicare/Medicaid regs

Education

Bachelor's degree in Nursing

Accredited School of Nursing

Job description

Position Title

Clinical Review Nurse - Concurrent Review

Work Location

Remote (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. This is usually every 4-5 th weekend 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

Education/Certification

• Required: Accredited School of Nursing or Bachelor's degree in Nursing
• Preferred:

Licensure

• Required: LPN/RN
• Preferred:

Years of experience

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
• 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.