Remote Clinical Review Nurse – Concurrent Review, WA

✨ About The Role

- The role involves performing concurrent reviews to determine the overall health of members, reviewing care being delivered, evaluating medical necessity, and contributing to discharge planning - Responsibilities include reviewing quality and continuity of care, working with Medical Affairs and/or Medical Directors, and documenting findings in health management systems - The position requires reviewing member transfer or discharge plans, collaborating with care management on member referrals, and providing feedback to leadership on opportunities to improve care - The candidate will work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings - The job also involves ensuring timely discharges between levels of care and facilities, complying with all policies and standards, and performing other duties as assigned

⚡ Requirements

- Requires a graduate from an Accredited School of Nursing or a Bachelor’s degree in Nursing with 2-4 years of related experience, preferably with 2+ years of acute care experience - Clinical knowledge and the ability to determine the overall health of members, treatment needs, and appropriate level of care are preferred - Knowledge of Medicare and Medicaid regulations, as well as utilization management processes, is beneficial for this role - State licensure is required for Registered Nurses (RN) or Licensed Practical Nurses (LPN) - The successful candidate should have strong communication skills to work with healthcare providers, provide education on utilization processes, and collaborate with care management