Remote Clinical Review Nurse - Utilization Management

Spectraforce Technologies, Inc.; Charleston (SC); Remote; USD 65,000 - 90,000; Full time

Job summary

Spectraforce Technologies, Inc. is seeking a Clinical Review Nurse for remote concurrent review responsibilities. The role assesses member health status, medical necessity, and appropriate care levels, contributing to discharge planning within care policies and guidelines.

Ideal candidates have 2–4 years of related experience (2+ years acute care UM or managed care preferred), nursing licensure, and a nursing degree. Remote work with EST preferred; CST considered.

Qualifications

• Accredited School of Nursing or Bachelor's degree in Nursing is required.
• Active LPN/RN licensure is required.
• 2–4 years of related experience; 2+ years acute care UM or managed care experience preferred.

Responsibilities

• Perform concurrent reviews to determine appropriate care level and health status.
• Review acuity, resource use, length of stay, and discharge planning.
• Collaborate with Medical Affairs/Medical Directors on member care discussions.
• Document concurrent review findings and discharge plans in health management systems.
• Coordinate with providers to approve determinations or provide recommendations based on findings.
• Educate providers on utilization processes to ensure appropriate care.
• Provide feedback to leadership on opportunities to improve care and medical necessity.
• Review transfer/discharge plans to ensure timely care transitions.
• Collaborate with care management on member referrals.
• Perform other duties as assigned and comply with policies and standards.

Skills

Clinical knowledge

UM processes

Medicare/Medicaid regs

Education

Bachelor's degree in Nursing

Accredited School of Nursing

Job description

Spectraforce Technologies, Inc. is seeking a Clinical Review Nurse for remote concurrent review responsibilities. The role assesses member health status, medical necessity, and appropriate care levels, contributing to discharge planning within care policies and guidelines.

Ideal candidates have 2–4 years of related experience (2+ years acute care UM or managed care preferred), nursing licensure, and a nursing degree. Remote work with EST preferred; CST considered.