Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct clinical and concurrent medical necessity assessments for the Ambetter team.

• Assess members' overall health, review the care being provided, evaluate medical necessity, and assist in discharge planning.

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

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

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

• Record concurrent review outcomes, discharge plans, and actions in health management systems.

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

• Educate providers on utilization processes.

• Provide leadership feedback on opportunities to enhance the level of care and medical necessity.

• Review transfer and discharge plans to ensure timely transitions across levels of care and facilities.

• Work together with care management on member referrals.

• Adhere to all policies and standards.

• Perform other assigned duties.

⛳️ Requirements

• Graduate from an accredited School of Nursing or possess a Bachelor’s degree in Nursing.

• 2–4 years of relevant experience.

• A minimum of 2 years of acute care experience.

• LPN state licensure is required.

• RN licensure necessary.

• Compact nursing license is highly preferred; Louisiana-licensed candidates may be considered if eligible and willing to obtain compact licensure.

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

• Familiarity with Medicare and Medicaid regulations is preferred.

• Knowledge of utilization management processes is preferred.

• Availability from Monday to Friday, 8:00 a.m. to 5:00 p.m., including a weekend rotation every 4th or 5th weekend and a flex day during the week.

• Must work at least one major holiday and two minor holidays.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement program.

• Paid time off along with holidays.

• Flexible work options with remote, hybrid, field, or office schedules.

• Total compensation may include additional incentives.