Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent evaluations to assess members’ overall health, suitable care, medical necessity, and required level of care.

• Analyze acuity levels, resource utilization, duration of stay, quality and continuity of care, and discharge planning.

• Collaborate with Medical Affairs and Medical Directors regarding the care of members.

• Record and maintain findings from 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 the appropriate level of care and medical necessity.

• Review transfer and discharge plans to ensure timely transitions between different levels of care and facilities.

• Work in conjunction with care management on member referrals.

• Adhere to policies and standards while performing other assigned responsibilities.

⛳️ Requirements

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

• 2–4 years of relevant experience.

• Minimum of 2 years of acute care experience is mandatory.

• Active RN license in California is required.

• Preferably possess clinical knowledge and the ability to assess the overall health of members, including treatment needs and suitable levels of care.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Required working schedule: Monday–Friday, 8:00 am–5:00 pm Pacific Standard Time (PST).

• Regular rotation on weekends and holidays is necessary.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements with options for remote, hybrid, field, or office schedules.

• Competitive compensation.

• Additional incentive options may be included in the overall compensation package.