Job Description
Position Title: Clinical Review Nurse - Concurrent Review
Work Location: Remote
Assignment Duration: 12 months
Work Schedule:Friday, Saturday, Sunday, Monday - 8am -6:30 pm CST
Work Arrangement: Remote
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.
| 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 - Compact as long as the licensure is unrestricted we are okay | Preferred: Compact | ||
| Must haves: Minimum 1 year nursing experience. Nice to haves: Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management Disqualifiers: n/a Performance indicators: Metric driven in production and quality | ||||
| 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 | |||
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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: $ 37.00/hr.