Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent reviews in an inpatient setting to evaluate medical necessity by utilizing InterQual criteria, corporate and state policies, along with available review tools.

• Provide support to New Hampshire Medicaid through the East Region Shared Services team.

• Carry out concurrent reviews to assess members’ overall health, suitable care, and appropriate level of care.

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

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

• Gather, document, and uphold concurrent review outcomes, discharge plans, and actions within health management systems.

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

• Educate providers on the utilization processes.

• Deliver leadership insights on opportunities for enhancing level-of-care and medical-necessity improvements.

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

• Work in conjunction with care management on member referrals.

• Adhere to all policies and standards while performing additional assigned responsibilities.

⛳️ Requirements

• Must be a graduate from 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.

• Clinical expertise and the capacity to evaluate the overall health of members, including treatment needs and suitable levels of care, are preferred.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• LPN state licensure is mandatory.

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

• Must be available to work from 8:00 a.m. to 5:00 p.m. Eastern Time.

• Weekend and holiday coverage is required based on team needs.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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

• Additional incentives may be included in total compensation.

• Equal opportunity employer committed to fostering diversity.