Nurse, Concurrent Review

HealthHelp • Houston, TX

2d • Remote

About The Position

The Nurse, Concurrent Review performs concurrent inpatient utilization review using InterQual criteria to determine whether requests meet medical necessity requirements. Reviews include admissions, continued stays, and transitional care in skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals, along with related follow-up and documentation. The nurse collaborates with physicians, hospitalists, care teams, and facility staff to gather clinical information, communicate clinical rationale, and support appropriate level-of-care decisions. The role also handles escalations and refers cases to Physician Reviewers or Specialty Program Medical Directors as appropriate.

The position applies applicable clinical criteria, medical policies, regulations, accreditation requirements, and payer-specific guidelines. It maintains accurate confidential documentation, meets expedited review timeframes, supports compliance and quality initiatives, and works with clients and providers to resolve concerns. Coverage may require non-standard business hours, weekends, or holidays based on client obligations and regulatory deadlines.

This is a 100% remote position with company-provided equipment. The scheduled shift is eight hours, Monday through Friday, between 7 a.m. and 5 p.m. PST (10 a.m. and 8 p.m. EST), with flexibility based on business needs. 100% attendance is required during the first 90 days. The start date is TBD.

Requirements

• Graduate of an accredited school of nursing; BSN preferred.
• Current, active, unrestricted RN license in a U.S. state or territory (USRN equivalent).
• At least two years of experience in an acute care setting.
• Proficient in Microsoft Office, including Word, Excel, and PowerPoint.
• Willingness to complete and maintain InterQual certification and ongoing competency requirements.
• Working knowledge of medical necessity criteria, level-of-care determination standards, payer-specific utilization review requirements, and insurance terminology.
• Good organizational and time management skills.
• Excellent written and verbal communication skills.
• Ability to use critical thinking skills.
• Highly motivated self-starter able to work efficiently and independently or as a team member.
• Ability to perform multiple tasks, prioritize work, and meet critical deadlines.
• Flexibility to support business needs, which may include alternative daytime hours, weekends, or holidays.

Nice To Haves

• BSN.
• Two years of inpatient clinical nursing, utilization management, or case management experience.
• Experience with InterQual or similar evidence-based clinical decision support criteria.
• Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning.
• Experience working with state and federal regulatory and compliance standards.

Responsibilities

• Perform concurrent inpatient utilization reviews using InterQual criteria, including admission, continued stay, and transitional care reviews.
• Complete related follow-up activities and documentation updates.
• Collaborate with attending physicians, hospitalists, care teams, and facility staff to obtain clinical information, discuss medical necessity, and support appropriate level-of-care decisions.
• Communicate clinical rationale during real-time concurrent review interactions.
• Facilitate resolution of escalated cases that may require special handling.
• Refer cases to a Physician Reviewer or Specialty Program Medical Director according to guidelines.
• Assist Physician Reviewers and Medical Directors in meeting review timeframes.
• Maintain written documentation according to HealthHelp policy and protect confidential information.
• Apply InterQual criteria, medical policies, and relevant regulatory, accreditation, and payer-specific requirements to inpatient review determinations.
• Adhere to HIPAA and applicable state and federal regulations, as well as URAC, NCQA, and other requisite standards.
• Work with Nursing Management to ensure consistent implementation of policies, procedures, and regulatory requirements.
• Stay current on regulatory changes and serve as a subject matter expert supporting Compliance Department initiatives and updates.
• Perform clinical intake and review cases according to HealthHelp policies and procedures, including cases requiring expedited turnaround times.
• Maintain availability for concurrent review coverage, which may include non-standard hours, weekends, or holidays.
• Identify and refer quality issues to UM Leadership.
• Collaborate with client personnel to resolve customer concerns and provide quality service to providers, administrative staff, and others.
• Support teamwork, respect, diversity, and cooperation, and participate in the HealthHelp Quality Management Program as required.
• Manage multiple tasks, prioritize projects, work independently under pressure, meet deadlines, and perform other related duties and projects as assigned.

Benefits

• Medical insurance
• Dental insurance
• Vision insurance
• Paid time off, holidays, and sick leave
• 401(k) with company match or other retirement plan
• Life and AD&D insurance
• Employee Assistance Program
• Potential eligibility for performance-based bonuses, incentive pay, or commissions

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree