Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conducts concurrent reviews, which involve assessing a member's overall health, examining the type of care provided, evaluating medical necessity, and aiding in discharge planning.

• Aids in the evaluation of inpatient services to confirm the necessity and appropriateness of the care being delivered to the member.

• Performs concurrent reviews of members to ensure appropriate care and settings are in place to assess overall health and the suitable level of care.

• Assesses the quality and continuity of care by analyzing acuity levels, resource usage, length of stay, and discharge planning.

• Collaborates with Medical Affairs and/or Medical Directors to discuss the care being provided to members.

• Gathers, documents, and preserves concurrent review findings, discharge plans, and actions taken on member medical records within health management systems.

• Partners with healthcare providers to approve medical determinations or to offer recommendations based on requested services and concurrent review findings.

• Aids in educating providers about utilization processes.

• Provides leadership with insights on opportunities to enhance the appropriate level of care and medical necessity.

• Reviews member transfer or discharge plans to ensure timely transitions between levels of care and facilities.

• Collaborates with care management for the referral of members as necessary.

• Performs additional duties as assigned.

⛳️ Requirements

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

• 2–4 years of relevant experience.

• Minimum of 2 years of acute care experience required.

• Clinical expertise and the capability to assess a member's overall health, including treatment needs and appropriate levels of care, preferred.

• Familiarity with Medicare and Medicaid regulations preferred.

• Understanding of utilization management processes preferred.

• LPN - Licensed Practical Nurse - State Licensure required.

• RN - Registered Nurse - State Licensure and/or Compact State Licensure.

• MO RN Licensure is highly preferred.

• Experience in post-acute care and/or utilization review is highly preferred.

• Adheres to all policies and standards.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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

• Additional incentive options may be included in the total compensation package.

• Equal opportunity employer committed to diversity.