Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent reviews to assess members' overall health, analyze delivered care, evaluate medical necessity, and assist with discharge planning.

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

• Review acuity levels, resource utilization, length of stay, and discharge plans.

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

• Gather, document, and uphold findings from concurrent reviews, discharge plans, and actions within health management systems.

• Partner with healthcare providers to authorize medical decisions or offer recommendations.

• Educate providers about utilization processes.

• Provide leadership with insights on opportunities to enhance the quality of care and medical necessity.

• Review transfer or discharge plans to ensure timely transitions across levels of care and facilities.

• Work together with care management on member referrals.

• Adhere to all policies and standards; perform other assigned tasks.

⛳️ Requirements

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

• 2–4 years of relevant experience.

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

• LPN state licensure is required.

• For Health Net of California: RN license is mandatory.

• For the State of Nevada: RN state licensure and/or Compact State Licensure is necessary.

• Clinical knowledge and the ability to assess overall health, treatment requirements, and suitable levels of care are preferred.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

🏝️ 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 incentive opportunities may be incorporated into total compensation