Clinical Review Nurse – Concurrent Review

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

📋 Description

• Assess inpatient admissions and elective procedures to verify medical necessity.

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

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

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

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

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

• Educate providers on utilization processes.

• Provide leadership insights on ways to enhance the level of care and establish medical necessity.

• Evaluate transfer and discharge plans to ensure timely transitions among care levels and facilities.

• Work in conjunction with care management on member referrals.

• Adhere to all policies and standards.

• Undertake other responsibilities as assigned.

⛳️ Requirements

• Applicants must reside in Mississippi.

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

• 2–4 years of relevant experience is required.

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

• LPN - Licensed Practical Nurse - State Licensure is necessary.

• For Health Net of California: RN license is required.

• RN - Registered Nurse - State Licensure and/or Compact State Licensure for the State of Nevada is required.

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

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Standard working hours are Monday through Friday.

🏝️ Benefits

• Health insurance.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off.

• Holidays.

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

• Additional incentive forms may be included in total compensation.

• Equal opportunity employer committed to diversity.