Clinical Review Nurse - Concurrent Review
Spectraforce
US
Remote
2 hours ago
Job Description
Position Title: Clinical Review Nurse - Concurrent Review
Work Location: Remote - NC license or Compact license
Assignment Duration: 12 months (contract to hire)
Work Schedule: 8 am-5 pm EST Mon - Fri, OT not required
Work Arrangement: Remote
Position Purpose:
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.
Education/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
For Health Net of California: RN license required
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
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: $ 38.00/hr.
Work Location: Remote - NC license or Compact license
Assignment Duration: 12 months (contract to hire)
Work Schedule: 8 am-5 pm EST Mon - Fri, OT not required
Work Arrangement: Remote
Position Purpose:
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.
Education/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
For Health Net of California: RN license required
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
| Candidate Requirements | ||||
| Required: Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. LPN | Preferred: RN | |||
| Required: NC license or Compact license | Preferred: | |||
| Must haves: 2 years of experience with IP auth reviews Nice to haves: Previous experience with NC State Criteria/ InterQual Criteria Disqualifiers: Performance indicators: 15 Auths reviews per day | |||
| 1 | Must have 2 years prior exp in IP with an insurance company | ||
| 2 | Must be a team Player | |||
| 3 | MS Office Suite | |||
Applicant Notices & Disclaimers
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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: $ 38.00/hr.