Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent reviews to assess members’ overall health, evaluate medical necessity, determine appropriate care type and setting, and assist in discharge planning.

• Assess inpatient services to confirm the necessity and appropriateness of care settings.

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

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

• Gather, document, and preserve findings from concurrent reviews, discharge plans, and actions taken in members’ medical records and health management systems.

• Engage with healthcare providers to endorse medical determinations or offer recommendations based on requested services and review outcomes.

• Educate providers on utilization management processes.

• Provide leadership insights on potential enhancements in care levels and medical necessity.

• Examine member transfer or discharge plans to facilitate timely transitions between various care levels and facilities.

• Partner with care management on member referrals.

• Perform additional duties as assigned and adhere to policies and standards.

⛳️ Requirements

• Must be a resident of Missouri.

• Active RN licensure in Missouri is required.

• Graduate from an accredited nursing program 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 necessary.

• A clinical background; experience in managed care and utilization management/review is advantageous.

• Preferred clinical knowledge to assess members’ overall health, treatment requirements, and suitable care levels.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• RN licensure and/or compact state licensure for Missouri Medicaid is required.

• Availability to work Monday through Friday, from 8 AM to 5 PM Central Time, with 1–2 rotational holidays per year.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement assistance.

• Paid time off.

• Holiday pay.

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

• Potential incentives included in total compensation.