Clinical Review Nurse – Concurrent Review

This is a fully remote position, open to applicants in Illinois, +1 more state.

📋 Description

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

• Analyze inpatient services to confirm the necessity and appropriateness of the care setting.

• Identify suitable care and level-of-care settings based on the overall health of members.

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

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

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

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

• Provide education to providers regarding utilization processes.

• Offer leadership insights on potential improvements in level of care and medical necessity.

• Examine transfer and discharge plans to guarantee timely transitions between various levels of care and facilities.

• Work together with care management on member referrals.

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

⛳️ Requirements

• LPN or RN license is mandatory.

• Compact License or licensure in Michigan or Illinois is required.

• Openness to obtaining licenses in additional states as needed.

• Graduation from an Accredited School of Nursing or possess a Bachelor’s degree in Nursing.

• 2–4 years of relevant experience is necessary.

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

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

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• LPN — Licensed Practical Nurse — State Licensure is required.

• RN — Registered Nurse — State Licensure and/or Compact State Licensure is required.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

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

• Additional incentive programs may be included in total compensation.

• Equal opportunity employer dedicated to promoting diversity.