Clinical - Clinical Review Nurse - Concurrent Review
About The Position
Pyramid Consulting is recruiting a Clinical Review Nurse for a 06+ months contract opportunity with long-term potential, located onsite in Dallas, Texas. The nurse performs concurrent reviews to determine appropriate care and care settings, evaluates quality and continuity of care, and collaborates with providers, Medical Affairs, Medical Directors, and care management. The role includes documenting review findings and discharge plans, supporting timely member transitions, and educating providers on utilization processes. The pay range is $36 to $39 per hour. Employee benefits include health insurance (medical, dental, and vision), a 401(k) plan, and paid sick leave depending on work location.
Requirements
- Registered Nurse (RN) required.
- Managed care organization (MCO)/managed care experience required.
- Denials management experience required.
- At least 2 years of acute care experience.
- Graduate from an accredited school of nursing or have a bachelor's degree in nursing.
Nice To Haves
- Knowledge of Medicare and Medicaid regulations.
- Familiarity with utilization management processes.
Responsibilities
- Perform concurrent reviews of members to determine appropriate care and setting.
- Evaluate quality and continuity of care by analyzing acuity levels, resource consumption, and discharge planning.
- Collaborate with Medical Affairs and Medical Directors regarding member care.
- Document and maintain concurrent review findings and discharge plans in health management systems.
- Work with healthcare providers to approve medical determinations based on concurrent review findings.
- Educate providers on utilization processes to ensure high-quality care.
- Provide feedback to leadership on opportunities for improvement in care levels and medical necessity.
- Review members' transfer or discharge plans for timely transitions.
- Collaborate with care management for appropriate member referrals.
- Comply with all policies and standards.
Benefits
- Health insurance (medical, dental, and vision).
- 401(k) plan.
- Paid sick leave, depending on work location.
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What This Job Offers
Job Type
Full-time
