Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct timely inpatient utilization reviews based on medical necessity criteria, health plan policies, and relevant standards.

• Evaluate clinical records and accurately document decisions made.

• Escalate suitable cases for review by the medical director.

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

• Support quality reviews, audits, and compliance initiatives.

• Oversee daily case load while adhering to quality standards, turnaround times, and productivity goals.

• Share clinical insights with colleagues and communicate recurring issues or opportunities for improvement to leadership.

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

• Analyze acuity levels, resource usage, length of stay, quality, continuity of care, and discharge planning.

• Engage with Medical Affairs and/or Medical Directors regarding members' care.

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

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

• Educate providers about utilization processes.

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

• Review transfer and discharge plans to ensure timely transitions.

• Work alongside care management on member referrals.

• Perform additional duties as assigned.

⛳️ 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 required.

• LPN (Licensed Practical Nurse) state licensure is required.

• For candidates in California: RN license is required.

• For candidates in the State of Nevada: RN (Registered Nurse) state licensure and/or compact state licensure is required.

• Preferred clinical knowledge and ability to assess overall health, treatment needs, and appropriate level of care.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Knowledge of utilization management processes is preferred.

• Adhere to all relevant policies and standards.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement assistance.

• Paid time off in addition to holidays.

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

• Additional incentives may be included in the total compensation package.

• Commitment to equal opportunity employment.