Clinical Review Nurse - Concurrent Review
About The Position
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. This position is remote/work from home and will support Illinois Medicaid and Ambetter utilization management. The position requires an Illinois RN licensure. The role is full-time, work hours are Monday - Friday, 8am - 5pm central time zone, and rotating weekends and holidays.
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 required
- LPN - Licensed Practical Nurse - State Licensure required
- RN - Registered Nurse - State Licensure the State of Illinois is required
Nice To Haves
- 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
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.
Benefits
- competitive pay
- health insurance
- 401K
- stock purchase plans
- tuition reimbursement
- paid time off
- holidays
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
