Clinical Review Nurse – Concurrent Review

This is a fully remote position, open to applicants in California.

📋 Description

• Conduct concurrent evaluations of inpatient medical admissions for both pediatric and adult members within the LA Medicaid sector.

• Assess members’ overall health status, suitable care, medical necessity, and level of care required.

• Analyze acuity levels, resource utilization, lengths of stay, and discharge planning processes.

• Collaborate with Medical Affairs and/or Medical Directors concerning member care.

• Gather, document, and preserve findings from concurrent reviews, discharge plans, and actions in health management systems.

• Partner with healthcare providers to authorize medical determinations or offer recommendations.

• Educate providers on utilization processes.

• Provide leadership with feedback on ways to enhance levels of care and medical necessity.

• Examine transfer and discharge plans to facilitate timely transitions between levels of care and facilities.

• Work alongside care management on member referrals.

• Adhere to policies and standards while executing other assigned tasks.

⛳️ Requirements

• Graduation from an Accredited School of Nursing or a Bachelor’s degree in Nursing.

• 2–4 years of applicable experience.

• A minimum of 2 years of acute care experience is mandatory.

• LPN state licensure is required, or RN state licensure and/or Compact State licensure.

• Preferred clinical knowledge and capability to assess the overall health of members, including treatment needs and appropriate care levels.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Standard working hours are 8am–5pm CST, including weekend and holiday rotations.

• Ability to perform clinical reviews of inpatient medical admissions for pediatric and adult members.

• Knowledge of utilization management policies and guidelines is essential.

🏝️ Benefits

• Health insurance.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off in addition to holidays.

• Flexible work arrangements, including remote, hybrid, field, or office schedules.

• Other forms of incentives may be included in total compensation.