Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent assessments to evaluate members’ overall health, appropriateness of care, and required level of care.

• Assess medical necessity and inpatient services.

• Analyze acuity levels, resource utilization, duration of stay, quality of care, continuity of care, and discharge planning.

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

• Record findings from concurrent reviews, discharge plans, and actions in health management systems.

• Engage with healthcare providers on medical determinations and recommendations.

• Educate providers on utilization procedures.

• Provide leadership insights on areas for enhancing level of care and medical necessity.

• Review transfer and discharge plans to ensure timely transitions.

• Partner with care management teams on member referrals.

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

⛳️ 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.

• Valid Illinois RN state licensure is mandatory.

• LPN state licensure is required.

• Preferred clinical knowledge and capability to assess overall health of members, including treatment requirements and suitable level of care.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Availability Monday through Friday, from 8 am to 5 pm Central Time, along with rotating weekends and holidays.

🏝️ Benefits

• Health insurance.

• 401K plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off in addition to holidays.

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

• Competitive salary.