This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

• Conduct concurrent reviews to assess members' overall health, the nature of care provided, medical necessity, and assist in discharge planning.

• Assess inpatient services to ensure the necessity and appropriateness of the care setting.

• Identify the suitable care and setting by analyzing acuity levels, resource utilization, length of stay, and discharge planning.

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

• Gather, document, and uphold findings from concurrent reviews, discharge plans, and actions taken within medical records and health management systems.

• Engage with healthcare providers to approve medical decisions or offer recommendations.

• Educate providers on utilization processes.

• Provide leadership with feedback on areas for enhancing the level of care and medical necessity.

• Review transfer or discharge plans to facilitate timely discharges.

• Work together with care management on member referrals.

• Adhere to all policies and standards.

• Carry out other assigned duties.

⛳️ Requirements

• Must be located in the EST or CST time zones.

• Experience in Med Surg is highly desirable.

• Must be a graduate from an accredited nursing school or hold a Bachelor's degree in Nursing.

• 2–4 years of relevant experience is required.

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

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

• Clinical expertise and the ability to assess the overall health of members, including treatment requirements and appropriate levels of care, are preferred.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.