Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct timely inpatient utilization reviews to ensure compliance with medical necessity criteria, health plan policies, and relevant standards.

• Analyze clinical records and accurately document decisions made.

• Escalate suitable cases for medical director assessment.

• Collaborate with providers, facilities, and internal teams to facilitate care coordination and support discharge planning.

• Assist in quality reviews, audits, and compliance initiatives.

• Manage daily case workload while achieving quality, turnaround time, and productivity targets.

• Share clinical insights with colleagues and bring recurring issues or opportunities for improvement to the attention of leadership.

• Conduct concurrent reviews to assess members’ overall health, appropriate care, and necessary level of care.

• Evaluate acuity levels, resource utilization, length of stay, quality of care, continuity of care, and discharge planning.

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

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

• Engage with healthcare providers to validate medical determinations or offer recommendations.

• Educate providers about utilization processes.

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

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

• Work together with care management on member referrals.

• Perform additional duties as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Graduate from an accredited nursing school or possess a Bachelor’s degree in Nursing.

• 2–4 years of relevant experience.

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

• LPN (Licensed Practical Nurse) - State Licensure is required.

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

• Familiarity with Medicare and Medicaid regulations is preferred.

• Knowledge of utilization management processes is preferred.

• Ability to comply with all policies and standards.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Opportunities for stock purchase plans.

• Tuition reimbursement program.

• Paid time off in addition to holidays.

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

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

• Equal opportunity employment.

• Consideration for qualified applicants with arrest or conviction records in accordance with applicable law.