Remote Clinical Review Nurse – Concurrent Review, Multiple Locations - Remote Eligible

✨ 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 collaborating with care management on member referrals - The position requires collecting, documenting, and maintaining concurrent review findings, discharge plans, and actions taken on member medical records - The candidate will also review member transfer or discharge plans to ensure timely transitions between levels of care and facilities - Additionally, the role involves providing feedback to leadership on opportunities to improve the appropriate level of care and medical necessity based on clinical policies and guidelines

⚡ Requirements

- Requires 2-4 years of related experience in acute care, with a Bachelor's degree in Nursing or a Graduate from an Accredited School of Nursing - 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 - Must hold a state licensure as a Licensed Practical Nurse (LPN), with a Compact License preferred - Ideal candidate should have experience working with healthcare providers to approve medical determinations or provide recommendations based on requested services