Position Title: Clinical Review Nurse – Concurrent Review
Work Location: Remote – Texas (CST)
Assignment Duration: 6 Months (Contract to Hire)
Work Schedule: Tuesday – Saturday, 8am–5pm CST (Training Mon–Fri 8–5)
Work Arrangement: Remote
Performs concurrent reviews, including determining 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 evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
Fast-paced clinical review team supporting medical necessity determinations. Nurse reviews faxed clinical documentation from facilities and works from task queues to meet daily deadlines.
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
Collects, documents, and maintains concurrent review findings
Works with healthcare providers to approve medical determinations
Provides education to providers on utilization processes
Provides feedback to leadership on care improvement opportunities
Reviews transfer or discharge plans
Collaborates with care management
Performs other duties as assigned
Complies with all policies and standards
Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
2–4 years related experience (4 preferred)
2+ years acute care experience required
Clinical knowledge to determine treatment needs and level of care
Knowledge of Medicare/Medicaid preferred
Knowledge of utilization management preferred