Clinical Review Nurse - Concurrent Review

About This Role

Perform concurrent reviews of member care to determine overall health, evaluate medical necessity, and contribute to discharge planning, ensuring appropriate care and setting.

Responsibilities

• Perform concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
• Review quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
• Work with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
• Collect, document, and maintain concurrent review findings, discharge plans, and actions taken on member medical records in health management systems
• Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
• Assist with providing education to providers on utilization processes to ensure high quality appropriate care to members
• Review member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Collaborate with care management on referral of members as appropriate

Requirements

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
• 2-4 years of related experience
• 2+ years of acute care experience
• LPN - Licensed Practical Nurse - State Licensure

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
• 2-4 years of related experience, including 2+ years of acute care experience

Nice to Have

• Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care
• Knowledge of Medicare and Medicaid regulations
• Knowledge of utilization management processes

Benefits