Registered Nurse - Concurrent Review

GuideWell; Florida; Hybrid; USD 71,000 - 116,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Retirement plan

Paid time off

Job summary

GuideWell in Florida is seeking a Clinical Review Nurse (CRN) to perform medical reviews and coordinate care from hospital to home, ensuring appropriate levels of care and reducing readmissions.

The role involves working with providers, evaluating beneficiaries across settings, and collaborating with Medical Directors and Case Management. Hybrid work with travel within Florida may be required.

Qualifications

• 2+ years related work experience; recent clinical experience in hospital/LTAC/Rehab/SNF evaluating benefit determination and level of care.
• Bachelor’s degree or related equivalent work experience in Nursing.
• Registered Nurse - Florida State Licensure and/or Compact State Licensure including Florida.

Responsibilities

• Serve as a point of contact for providers to assist in navigating members through the continuum and educate regarding benefits.
• Evaluate members in hospital/ SNF settings for benefit determination and medical necessity using InterQual or criteria.
• Participate in weekly case review.
• Determine member discharge status and coordinate ongoing Care Coordination services.

Skills

Registered Nurse (RN) license

Care coordination

Discharge planning

Utilization review

MS Word

Excel

Education

Bachelor’s degree in Nursing

Tools

MS Word

Excel

Job description

The CRN is responsible for performing medical reviews using established criteria to ensure the member is receiving care at the most appropriate level. The CRN builds relationships with facility case managers to facilitate appropriate care and discharge planning. The CRN is responsible for identifying appropriate care programs for members to ensure a smooth transition from facility to home and to decrease frequency of readmission.

What You Will Be Doing

• Serve as a point of contact for providers to assist in navigating members them through the continuum, educate regarding benefits, identify candidates for Care Programs and provide information pertaining to the network and network access
• Evaluate members in the Hospital, Skilled Nursing Facility, LTAC, Acute Inpatient Rehab for benefit determination, medical necessity and appropriate level of care utilizing member benefits and InterQual or other medical necessity criteria.
• Participate in weekly case review
• Determine member's discharge status and identify and coordinate any additional needs and services that require ongoing Care Coordination services
• Collaborate with Medical Directors, Managers, Co-workers and other departments including Case Management and Care Partners

What We Require

• 2+ years related work experience; recent (within the past 3-5 years) clinical experience in a hospital, LTAC, Rehab, SNF setting evaluating hospital benefit determination, medical necessity and appropriate level of care
• Related Bachelor’s degree or additional related equivalent work experience Nursing
• Registered Nurse - Florida State Licensure and/or Compact State Licensure including the state of Florida
• Experience in one or more of the following: home health care, rehab, SNF, utilization review, discharge planning or case management Referrals for possible
• Case Management activities that focus on acute and non-acute services, outpatient services and/or community resources
• Experience with the Healthcare industry and Managed Care Experience in MS Word and Excel Moderate to heavy keying required
• Occasional travel within the State of Florida

What We Prefer

• Bachelor’s degree Nursing, Healthcare or Business
• Unrestricted US RN license
• Case Management Certifications (ACM or CCM)

General Physical Demands

• Exerting up to 10 pounds of force occasionally to move objects.
• Jobs are sedentary if traversing activities are required only occasionally.
• This position offers a hybrid work arrangement which combines flexibility with in office engagement. Team schedules are determined based on role requirements and business needs. Travel to and from our corporate offices may be required.

What We Offer

As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan including employer match
• Paid time off, volunteer time off, 10 holidays and 2 well-being days
• Additional voluntary benefits available; and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Typical Annualized Offer/Hiring Range:

$71,200 - $89,000

Annualized Salary Range:$71,200 - $115,700

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.