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. Applicants for this role have the flexibility to work remotely from their home. The position requires an Iowa or compact nursing license. Previous utilization management, Med/Surg, ICU, and/or pediatric experience is preferred. The work schedule is Monday - Friday, 8am - 5pm Central. Participating in a rotating weekend and holiday schedule is required.
Requirements
- Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
- 2+ years of acute care experience required.
- LPN - Licensed Practical Nurse - State Licensure required
Nice To Haves
- Previous utilization management, Med/Surg, ICU, and/or pediatric experience is preferred.
- 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.
Benefits
- competitive pay
- health insurance
- 401K
- stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
