Clinical Review Nurse - Concurrent Review

Spectraforce Technologies; Texas City (TX); Remote; USD 70,000 - 85,000; Full time

Job summary

A leading healthcare company is seeking a Clinical Review Nurse to perform concurrent reviews and assess members' health needs. This remote position requires collaboration with medical teams and documentation of care processes. Ideal candidates will have a nursing degree and experience in utilization management, with knowledge of Medicare and Medicaid regulations preferred.

Qualifications

• 2-4 years of related experience preferred.
• Knowledge of Medicare and Medicaid regulations is preferred.

Responsibilities

• Perform concurrent reviews to assess member's overall health.
• Collaborate with Medical Affairs regarding member care.
• Document review findings and maintain discharge plans.

Skills

Clinical Knowledge

Assessment Skills

Utilization Management

Education

Bachelor's Degree in Nursing

Job description

Title: Clinical Review Nurse - Concurrent Review

Duration: 6 Months (Possible extension)

Location: Remote - Texas (8am-5pm CST)

Description:

Performs concurrent reviews, including assessing the 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 in evaluating inpatient services to validate the necessity and appropriateness of the care setting for the member.

Education/Experience:

• Graduate from an accredited school of nursing or a bachelor's degree in nursing.
• 2-4 years of related experience preferred.
• Clinical knowledge and ability to assess the overall health of the member, including treatment needs and appropriate level of care, are preferred.
• Knowledge of Medicare and Medicaid regulations is preferred.
• Knowledge of utilization management processes is preferred.

License/Certification:

• RN - Registered Nurse, State Licensure required.
• Performs concurrent reviews to determine appropriate care and setting, and to assess overall health and care needs.
• Reviews quality and continuity of care by examining acuity level, resource consumption, length of stay, and discharge planning.
• Collaborates with Medical Affairs and/or Medical Directors regarding member care.
• Documents and maintains review findings, discharge plans, and actions in health management systems according to policies.
• Works with healthcare providers to approve or recommend services based on review findings.
• Provides education to providers on utilization processes to ensure high-quality, appropriate care.
• Provides feedback to leadership for process improvements related to care appropriateness and medical necessity.
• Reviews transfer or discharge plans for timely execution between care levels and facilities.
• Collaborates with care management on member referrals.
• Performs other duties as assigned.