Clinical Review Nurse - Concurrent Review
About The Position
Performs concurrent reviews for inpatient members, assessing overall health, the care being delivered, medical necessity, and discharge planning in accordance with care policies and guidelines. Assists in evaluating inpatient services to validate the necessity and setting of care. This fully remote, work-from-home role supports Market Place/Ambetter members across multiple states and is open to applicants residing in Arizona, Nevada, Oregon, or Washington. The schedule is Monday through Friday, 8 a.m. to 5 p.m. in the employee’s local time zone, with rotational weekends and holidays. The role supports inpatient members; acute rehabilitation, skilled nursing facility (SNF), or long-term care (LTC) experience is considered ideal. Compact RN licensure is preferred, or the ability to obtain additional state licenses as needed; license costs are reimbursed by the company.
Requirements
- Graduate of an accredited school of nursing or a bachelor’s degree in nursing.
- Two to four years of related experience.
- At least two years of acute care experience.
- LPN state licensure is required for LPNs.
- RN state licensure and/or compact state licensure for the State of Nevada is required for RNs.
- Applicants must reside in Arizona, Nevada, Oregon, or Washington.
- Ability to work Monday through Friday, 8 a.m. to 5 p.m. in the employee’s time zone, with rotational weekends and holidays.
Nice To Haves
- Acute rehabilitation, SNF, or LTC experience.
- RN compact nursing licensure, or ability to obtain licenses in other states as needed.
- Clinical knowledge and ability to determine a member’s overall health, treatment needs, and appropriate level of care.
- Knowledge of Medicare and Medicaid regulations.
- Knowledge of utilization management processes.
Responsibilities
- Perform concurrent reviews to assess members’ overall health, appropriate care, and appropriate level and setting of care.
- Review quality and continuity of care by evaluating acuity, resource consumption, length of stay, and discharge planning.
- Work with Medical Affairs and/or Medical Directors as needed to discuss member care.
- Collect, document, and maintain concurrent review findings, discharge plans, and actions taken in member medical records in health management systems, following utilization management policies and guidelines.
- Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
- Educate providers on utilization processes to support high-quality, appropriate care for members.
- Provide leadership with feedback on opportunities to improve appropriate levels of care and medical necessity in accordance with clinical policies and guidelines.
- Review member transfer or discharge plans to support timely transitions between levels of care and facilities.
- Collaborate with care management on referrals as appropriate.
- Perform other duties as assigned.
- Comply with all policies and standards.
Benefits
- Health insurance
- 401(k)
- Stock purchase plans
- Tuition reimbursement
- Paid time off and holidays
- Flexible approach to work, including remote, hybrid, field, or office schedules
- Reimbursement for costs of obtaining additional state licenses as needed
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
