Clinical Review Nurse - Concurrent Review

Axelon Services Corporation; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Axelon Services Corporation is seeking a Nursing professional for a 6-month remote role focused on concurrent reviews and utilization management. The candidate will assess member health, determine appropriate care levels, and collaborate with Medical Affairs to support quality of care.

The position requires an RN or LPN license, a nursing degree, and at least 2 years of related and acute care experience. Candidates should be familiar with Medicare/Medicaid regulations and be prepared for

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• Minimum 2 years of related experience.
• 2 years of acute care experience required.
• Clinical knowledge to determine overall member health and need for care.
• Knowledge of Medicare/Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• LPN license required.
• RN license required for Health Net of California.
• RN license and/or compact license for Nevada required.

Responsibilities

• Perform concurrent reviews of members to determine appropriate care level.
• Review quality and continuity of care by assessing acuity, resource use, LOS, and discharge planning.
• Collaborate with Medical Affairs/Medical Directors as needed.
• Document findings and discharge plans in health management systems per policies.
• Work with healthcare providers to approve determinations or provide recommendations.
• Educate providers on utilization processes to ensure high‑quality care.
• Provide feedback to leadership on opportunities to improve care levels and medical necessity.
• Review transfer or discharge plans for timely escalation between levels of care.
• Collaborate with care management on referrals.
• Perform other duties as assigned and comply with policies.

Education

Bachelor's degree in Nursing

Job description

Work Mode: 100% Remote, Source candidates from EST preferred but will consider CST candidates.

Duration: 6 months

Eastern 8-5 PM M - F with expected weekend and holiday coverage based on team needs. This is usually every 4-5th weekend but can change. Working holidays are expected under a rotated schedule.

Responsibilities:

• Perform concurrent reviews of members for appropriate care and setting to determine overall health and appropriate level of care.
• Review quality and continuity of care by assessing acuity level, resource consumption, length of stay, and discharge planning of members.
• Collaborate with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered.
• Collect, document, and maintain concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines.
• Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
• Assist with providing education to providers on utilization processes to ensure high-quality appropriate care to members.
• Provide feedback to leadership on opportunities to improve appropriate level of care and medical necessity based on clinical policies and guidelines.
• Review member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collaborate with care management on referral of members as appropriate.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements:

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• Minimum 2 years of related experience.
• 2 years of acute care experience required.
• 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.
• LPN - Licensed Practical Nurse - State Licensure required.
• For Health Net of California: RN license required.
• RN - Registered Nurse - State Licensure and/or Compact State Licensure for State of Nevada required.

Preferred Skills:

• Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care.
• Knowledge of Medicare and Medicaid regulations.
• Knowledge of utilization management processes.