Clinical Review Nurse - Concurrent Review

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

Job summary

Spectraforce Technologies, Inc. is seeking a Clinical Review Nurse for remote work with a Central Time Zone schedule. The role involves concurrent reviews, determining level of care, and contributing to discharge planning.

Qualifications include a nursing degree (AS or higher) and compact nursing licensure (RN/LPN/LVN). Requires 1+ years of experience and comfort working remotely with weekend/holiday rotation as needed.

Qualifications

• Education: High school diploma or nursing degree (AS or higher).
• Licensure: Compact Nursing License (RN, LPN, LVN).
• Experience: 1+ years in a clinical review/acute care setting.

Responsibilities

• Perform concurrent reviews to determine appropriate level of care and care settings.
• Assess medical necessity and contribute to discharge planning.
• Collaborate with Medical Affairs/Medical Directors as needed.
• Document findings in health management systems per utilization management policies.
• Coordinate with providers to discuss determinations and recommendations.
• Educate providers on utilization processes to ensure appropriate care.
• Provide feedback to leadership on opportunities to improve care and medical necessity.
• Review transfer or discharge plans to ensure timely transitions.
• Collaborate with care management on referrals as appropriate.
• Perform other duties as assigned.

Skills

Independent work

Team player

Organizational skills

Education

Nursing degree (AS or higher)

High school diploma

Job description

Position Title: Clinical Review Nurse - Concurrent Review

Work Location: Remote, Compact Nursing License Required, Central Time Zone Work Schedule

Assignment Duration: 12-Month Contract to Hire

Work Schedule: Mon-Friday, 11 AM to 8 PM CST; Weekends and Holidays on a rotation basis based on business needs. Possible 10-Hour, 4-day work week if it aligns with the candidate.

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 the 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

Qualification & Experience:

Candidate Requirements

Education/Certification

Required: Required: Highschool Diploma, Nursing Degree- Associates or Above

Preferred:

Licensure

Required: Compact Nursing License-RN, LPN, LVN.

Preferred:

Years of experience required

1+ years,

Disqualifiers: Inability to work possible weekend hours and holidays on a rotation basis as applicable or needed by business needs

Additional qualities to look for: MCO experience, specifically with Medicaid, True Care Cloud experience is a bonus, experience working remote

Top 3 must-have hard skills stack-ranked by importance

• 1 Ability to complete work independently and with minimal supervision after training.
• 2 Team player
• 3 Great organizational skills