Clinical Review Nurse - Concurrent Review

Pyramid Consulting, Inc; Sugar Land (TX); Remote; Full time

Job summary

An established industry player is seeking a talented Clinical Review Nurse for a remote contract opportunity in Texas. This role involves reviewing medical documents and authorizations, ensuring compliance with tight deadlines. The ideal candidate will have a strong background in Utilization Management, ICU, or ER, and possess excellent documentation and communication skills. Join a leading healthcare firm that values your expertise and offers a supportive environment. If you are ready to make a significant impact in patient care and thrive in a fast-paced setting, this is the perfect opportunity for you.

Benefits

Health insurance (medical, dental, vision)

401(k) plan

Paid sick leave

Mileage reimbursement

Qualifications

• Must possess a TX RN License or Compact State RN License.
• Experience in ICU or ER with a background in Utilization Management.

Responsibilities

• Review documents and complete authorization reviews within 24 hours.
• Achieve individual hourly productivity of 2.49-3.21.

Skills

Utilization Management

ICU

Case Management

Documentation Skills

Communication Skills

InterQual Knowledge

Education

Registered Nurse

BSN

Tools

Microsoft Office

Excel

Job description

Clinical Review Nurse - Concurrent Review

Immediate need for a talented Clinical Review Nurse - Concurrent Review. This is a 06+ Months Contract opportunity with long-term potential and is located in TX (Remote). Please review the job description below and contact me ASAP if you are interested.

Job ID: 25-56634
Pay Range: $36 - $40/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location). Additional mileage reimbursement.

Key Responsibilities:

• Responsible for reviewing handwritten and computer-generated documents while prioritizing tasks effectively.
• Complete authorization reviews within 24 hours, as TX has a very tight time frame.
• Send cases that do not meet medical necessity criteria for inpatient stay to a medical director for review.
• Follow up with the UM department at the hospital for denied authorizations to offer a peer-to-peer review before sending an official denial.
• Complete authorization reviews within a 24-hour turnaround time; expected to handle about 12-20 authorizations per day.
• Handle a mix of new and concurrent reviews.
• Achieve individual hourly weighted productivity of 2.49-3.21 to meet expectations.
• Send cases that do not meet medical necessity criteria to the medical director; maintain a Concurrent Review Referral Rate of 30%-40%.
• Complete any Enterprise Compliance courses timely within the University.

Key Requirements and Technology Experience:

• Skills: Utilization Management, ICU, Case Management.
• Experience in ICU or ER, with a background in Utilization Management.
• Strong computer, documentation, and communication skills are essential.
• Ability to toggle between different screens quickly due to high volume in Texas.
• InterQual experience and knowledge of the Ambetter line of business is a plus.
• Must possess a TX RN License or Compact State RN License.
• Education Requirement: Registered Nurse.
• Education Preferred: BSN, ICU/ER experience.
• Required Certifications: TX RN License or Compact State License.
• Strong skills in documentation and communication.
• Proficiency in Microsoft Office and Excel.
• Location: TX Remote.
• Shift Time & Working Days: Monday through Friday 8am to 5pm (CST).

Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.