Clinical Review Nurse - Concurrent Review

Spectraforce Technologies; Los Angeles (CA); Remote; USD 80,000 - 95,000; Full time

Job summary

A healthcare staffing firm is looking for a Clinical Review Nurse for remote work in California. The role requires a valid California RN license and 2-4 years of experience in concurrent review. Responsibilities include reviewing member discharge plans, collaborating with healthcare teams, and ensuring high-quality care. The ideal candidate is tech-savvy and has strong communication skills.

Qualifications

• California RN license is required.
• 2-4 years of related experience in concurrent review or Interqual experience.
• Background with Centene preferred and Trucare experience is a plus.

Responsibilities

• Review members' transfer or discharge plans for timely discharge.
• Meet productivity expectations of 17-20 reviews a day.
• Collaborate with interdepartmental teams on clinical review projects.
• Educate providers on utilization processes for high-quality care.
• Manage and maintain concurrent review findings in health systems.

Skills

Communication skills

Attention to detail

Tech savvy

Education

ADN or above, graduate from accredited school of nursing

Bachelor's degree in Nursing

Tools

Interqual

OneNote

Microsoft Word

Excel

Teams

Job description

Overview

Position Title: Clinical Review Nurse - Concurrent Review

Work Location: Remote - California, must reside in CA or hold a CA license, and work hours listed

Assignment Duration: 12 months (Extension & Contract-to-hire)

Work Schedule: Training 8 am-5 pm PST for about a month; work schedule 8 am-5 pm PST

Work Arrangement: Remote

Responsibilities

• Reviews member\'s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Productivity expectations: 17-20 reviews a day with quality expectations met
• Partners with interdepartmental teams on projects within utilization management as part of the clinical review team
• Collaborates with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
• Assesses members and/or families for post-discharge needs and provides education on discharge planning options based on diagnoses, prognoses, resources, and/or preferences
• Manages 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
• Manages and collaborates with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
• Provides education to providers on utilization processes to ensure high-quality, appropriate care to members
• Partners with leadership to identify opportunities to improve appropriate level of care and medical necessity based on clinical policies and guidelines
• Oversees concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
• Provides insight and guidance on concurrent reviews to determine overall health of member, review the type of care being delivered, and approve treatment needs including discharge planning
• Provides guidance and expert knowledge to the utilization management team to address issues and validate the necessity and setting of care being delivered to the member
• Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning
• Oversees 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
• Provides subject matter expertise based on prior experience as well as training to other team members
• Manages reporting to identify trends and provides recommendations to various teams
• Performs other duties as assigned
• Complies with all policies and standards

Candidate Requirements

Education/Certification

ADN or above. Requires graduate from an accredited school of nursing or bachelor\'s degree in Nursing and 2-4 years of related experience. Preferred.

Licensure

Required: California RN license ONLY. Preferred: CA licensure or additional qualifications as applicable.

Years of experience required: 2-4 years of related experience - concurrent review / Interqual experience. Preferred: Background with Centene highly preferred; Trucare experience.

Disqualifiers: unmotivated, inability to work autonomously, no time off for first 90 days.

Additional Qualifications

• Top 3 must-have hard skills stack-ranked by importance
• 1) Communication skills are a must
• 2) FAST PACED, attention to detail, tech savvy
• 3) Interqual, one note, Word, Excel, Teams

Note: The information above is for candidate consideration and reflects the requirements and expectations for the role.