Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent reviews to assess the overall health of members, the appropriateness of care, and the required level of care.

• Analyze acuity levels, resource utilization, duration of stay, and discharge planning.

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

• Gather, document, and maintain records of concurrent review findings, discharge plans, and actions within health management systems.

• Partner with healthcare providers to authorize medical determinations or offer recommendations based on the requested services and review findings.

• Provide education to providers about utilization processes.

• Offer leadership insights on opportunities to enhance the level of care and validate medical necessity.

• Evaluate transfer and discharge plans to facilitate timely transitions across different levels of care and facilities.

• Work alongside care management on member referrals.

• Undertake additional responsibilities as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Bachelor’s degree in Nursing (BSN) or graduation from an accredited nursing program.

• 2 to 4 years of relevant experience.

• LPN (Licensed Practical Nurse) state licensure is mandatory.

• An active and unrestricted New York State Registered Nurse (RN) license is strongly preferred.

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

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Availability to work Monday through Friday from 8:30 AM to 5:00 PM ET, including a one-hour lunch break.

• Compliance with all policies and standards.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off in addition to holidays.

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

• Additional forms of incentives may be included in total compensation.

• Equal opportunity employment.

• Consideration of qualified applicants with arrest or conviction records, in accordance with applicable law.