Clinical Review Nurse – Concurrent Review

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

📋 Description

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

• Analyze inpatient services to confirm the necessity and appropriate setting of care.

• Identify suitable care levels and settings based on the health status of members.

• Review the quality and continuity of care, including factors such as acuity, resource use, length of stay, and discharge planning.

• Engage in discussions regarding member care with Medical Affairs and/or Medical Directors as necessary.

• Gather, document, and preserve review findings, discharge plans, and actions within medical records and health management systems.

• Collaborate with healthcare providers to secure medical determinations or offer recommendations.

• Educate providers on utilization processes.

• Provide feedback to leadership regarding opportunities for improvement in care levels and medical necessity.

• Review transfer and discharge plans to facilitate timely transitions.

• Work in conjunction with care management on member referrals.

• Adhere to policies and standards while performing additional assigned duties.

⛳️ Requirements

• Graduate from an accredited nursing school or possess a Bachelor’s degree in Nursing.

• 2–4 years of relevant experience.

• At least 2 years of acute care experience.

• Active and unrestricted New York State Registered Nurse (RN) license is strongly preferred for consideration.

• LPN state licensure is required.

• Clinical expertise to assess member health, treatment needs, and appropriate care levels is preferred.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Ability to work Monday–Friday, 8:30 AM–5:00 PM Eastern Time, including a one-hour lunch break.

• Capability to work entirely remotely.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase opportunities.

• Tuition reimbursement assistance.

• Paid time off.

• Paid holidays.

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

• Potential incentives may be included in total compensation.