Clinical Review Nurse - Concurrent Review

Centene Corporation•Remote-FL, FL

1d•$27 - $49•Remote

About The Position

This position performs concurrent reviews to assess medical necessity using InterQual criteria, corporate and state policies, and available review tools. The Clinical Review Nurse supports New Hampshire Medicaid through the East Region Shared Services team. The role involves determining a 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. The nurse will assist in evaluating inpatient services to validate the necessity and setting of care being delivered to the member. This role also involves working with Medical Affairs and/or Medical Directors, collecting and documenting review findings, working with healthcare providers to approve medical determinations or provide recommendations, educating providers on utilization processes, providing feedback to leadership on improvement opportunities, reviewing member transfer or discharge plans, and collaborating with care management.

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 and/or Compact State Licensure For State of Nevada required

Nice To Haves

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.

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.