Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct prompt inpatient utilization reviews in accordance with medical necessity criteria, health plan policies, and relevant standards.

• Examine clinical records, document decisions made, and refer suitable cases for medical director evaluation.

• Facilitate care coordination and assist with discharge planning alongside providers, facilities, and internal teams.

• Support quality reviews, audits, and compliance initiatives.

• Handle daily case loads while fulfilling quality, turnaround time, and productivity expectations.

• Share clinical knowledge 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, and discharge planning.

• Collaborate with Medical Affairs, Medical Directors, and care management teams.

• Document concurrent review findings, discharge plans, and actions within health management systems.

• Approve medical determinations or suggest recommendations based on requested services and review outcomes.

• Educate providers regarding utilization procedures.

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

• Carry out additional tasks as assigned and adhere to all policies and standards.

⛳️ Requirements

• Must be a graduate of an Accredited School of Nursing or possess a Bachelor’s degree in Nursing.

• 2–4 years of relevant experience is required.

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

• LPN state licensure is mandatory.

• An RN license is required for Health Net of California.

• RN state licensure and/or Compact State Licensure is required for the state of Nevada.

• Clinical expertise and the ability to ascertain overall health, treatment requirements, and appropriate care level are preferred.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off plus holidays.

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

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

• Commitment to equal opportunity employment and consideration in accordance with applicable laws.