Concurrent Review RN

P3 Health Partners•Salem, OR

1d•$90,000 - $100,000•Hybrid

About The Position

P3 Health Partners is seeking a Concurrent Review RN to play a critical role in ensuring patients receive the right care, at the right time, and in the most appropriate setting. In this role, you'll work closely with hospitals, physicians, specialists, care teams, and health plan partners to support appropriate utilization of healthcare resources, facilitate smooth care transitions, and improve patient outcomes. Your expertise will directly contribute to P3's commitment to the Quadruple Aim: improving health outcomes, enhancing the patient and provider experience, and reducing the cost of care.

Requirements

Graduate of an accredited School of Nursing.
Active Registered Nurse (RN) license in Oregon with the ability to obtain and maintain licensure in multiple states.
Minimum of four (4) years of clinical nursing experience.
Minimum of two (2) years of experience in a managed care, Medicare Advantage, or HMO environment.
Experience conducting medical necessity reviews and applying evidence-based clinical guidelines.
Strong clinical knowledge of acute, post-acute, and transitional care management.
In-depth understanding of utilization management principles and medical necessity review processes.
Experience applying evidence-based criteria, including InterQual, MCG, and CMS guidelines.
Excellent communication skills with the ability to interact effectively with physicians, hospital personnel, patients, and families.
Strong critical thinking, assessment, and problem-solving abilities.
Ability to navigate complex or sensitive discussions regarding level of care and service authorization decisions.
Exceptional organizational skills with the ability to manage multiple priorities and deadlines.
Proficiency with Microsoft Office applications and medical management software platforms.
Ability to work independently while collaborating effectively within interdisciplinary teams.
Adaptability and commitment to continuous learning in an evolving healthcare environment.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Previous Emergency Department (ED) experience.
Previous Intensive Care Unit (ICU) experience.
Experience in Case Management and/or Utilization Management.
Experience working with InterQual, MCG, CMS guidelines, and transitions of care programs.

Responsibilities

Promote the mission, vision, and values of P3 Health Partners.
Perform telephonic and onsite utilization reviews, including prior authorization, concurrent review, and transition of care evaluations.
Review and approve services within scope of authority and escalate cases requiring additional review when appropriate.
Apply evidence-based review criteria, including: Health plan benefits, CMS guidelines, Local and National Coverage Determinations (LCD/NCD), InterQual and MCG criteria.
Utilize clinical judgment to assess medical necessity, level of care, and appropriate service utilization.
Collaborate with hospitals, providers, and internal stakeholders to support discharge planning and care transitions.
Request and review additional clinical documentation to support utilization review decisions.
Escalate complex cases and medical necessity questions to the Medical Director as needed.
Coordinate care with physicians, specialists, emergency department personnel, patients, and families.
Partner with provider network teams and Medical Management departments to align care plans and support positive patient outcomes.
Educate providers and clinical staff regarding utilization management processes, criteria, and requirements.
Serve as a clinical resource and subject matter expert for non-clinical team members.
Identify opportunities to close care gaps and improve patient outcomes.
Accurately document all clinical reviews, communications, and decisions within designated systems.