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, care appropriateness, medical necessity, and care level.

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

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

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

• Partner with healthcare providers on medical determinations and recommendations.

• Educate providers about utilization processes.

• Offer leadership insights on enhancements regarding the appropriate level of care and medical necessity.

• Review transfer and discharge plans to facilitate timely transitions between different care levels and facilities.

• Work alongside care management on member referrals.

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

⛳️ Requirements

• An active, unrestricted Compact RN License is required.

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

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

• 2 to 4 years of relevant experience is preferred.

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

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Prior experience in UM, UR, Case Management, or Care Management is preferred.

• Candidates residing in Missouri will be given preference.

🏝️ Benefits

• Health insurance

• 401K

• Stock purchase plans

• Tuition reimbursement

• Paid time off plus holidays

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

• Additional incentives may be included in total compensation