Position Title: Clinical Review Nurse - Concurrent Review
Work Location: Texas (Remote)
Assignment Duration: 12 Months
Work Arrangement: Remote
Work Schedule: Monday through Friday, 9:30 AM to 6:00 PM CST

Position Summary:
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.

Key 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

Qualification & Experience:

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 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.
• License/Certification: LPN - Licensed Practical Nurse - State Licensure required

Education/Certification	Required: Requires graduated from an accredited school of nursing or Bachelor’s degree in nursing			Preferred: 2-4 years of related experience
Licensure	Required: LPN or RN,, Tx or Compact			Preferred: Compact
Years of experience required Disqualifiers Best vs. average Performance indicators		Must haves: Minimum 1 year nursing experience.   Nice to haves: Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management   Disqualifiers:   Performance indicators: Metric driven in production and quality
Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection		1	Ability to critically think
		2	Ability to effectively use Microsoft OneNote and Word
		3	Ability to work remotely, i.e. meet production deadlines; quality metrics

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 35.00/hr.