Clinical Review Nurse - Concurrent Review

Spectraforce Technologies; Phoenix (AZ); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider is seeking a Clinical Review Nurse for remote work. This role involves performing concurrent reviews, evaluating medical necessity, and collaborating with healthcare providers to ensure quality care. Candidates should have a nursing degree and a compact nursing license. Documentation experience is essential, with additional skills in denial writing being a plus.

Qualifications

• Knowledge of Medicare and Medicaid regulations preferred.
• Clinical knowledge and ability to determine overall health of member.

Responsibilities

• Performs concurrent reviews and evaluates medical necessity.
• Works with healthcare providers to approve medical determinations.
• Collects and maintains concurrent review findings.

Skills

Documentation

Education

2 year or 4 year nursing degree

Job description

Title: Clinical Review Nurse - Concurrent Review

Duration: 03 Months (Potential to extend or Hire )

Location: Remote - AZ, CO, or LA

Shift: 12- 9 CST

Must be able to work a Saturday or Sunday each week.



Responsibilities:

• 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.


• 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.


• 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

Candidate Requirements
Education/Certification	Required: 2 year or 4 year nursing degree.	Preferred:
Licensure	Required: Compact nursing license (RN or LPN).	Preferred:

Must-haves:

• Documentation experience

Nice to have:

• Denial writing experience.