Inpatient Utilization Review Nurse (Concurrent Review)

NurseRemotely; United States; Remote; USD 80,000 - 105,000; Full time

Job summary

NurseRemotely is seeking a nurse reviewer to perform concurrent reviews, determine appropriate care levels, and support discharge planning under utilization management guidelines.

The role requires nursing accreditation and 2+ years of acute care experience, with familiarity in Medicare/Medicaid regulations and hospital-based care processes. You will collaborate with Medical Affairs and providers to ensure medically necessary care and timely transitions.

Qualifications

• Associate degree is required.
• Bachelor's degree in Nursing is preferred.
• Current RN license required (MS or Compact).
• 2 years of related experience; 2+ years acute care experience preferred.

Responsibilities

• Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
• 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

Skills

Basic Computer Knowledge

Critical Thinking Skills

Time Management/Organized

Education

Associate degree

Bachelor's degree in Nursing

Job description

NurseRemotely is seeking a nurse reviewer to perform concurrent reviews, determine appropriate care levels, and support discharge planning under utilization management guidelines.

The role requires nursing accreditation and 2+ years of acute care experience, with familiarity in Medicare/Medicaid regulations and hospital-based care processes. You will collaborate with Medical Affairs and providers to ensure medically necessary care and timely transitions.