Clinical Review Nurse – Concurrent Review

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

📋 Description

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

• Evaluates the quality and continuity of care, including acuity level, resource utilization, duration of stay, and discharge planning.

• Collaborates with Medical Affairs and/or Medical Directors to discuss care for members.

• Gathers, documents, and preserves findings from concurrent reviews, discharge plans, and actions within health management systems.

• Works alongside healthcare providers to authorize medical determinations or offer recommendations based on requested services and review findings.

• Provides education to providers on utilization processes to ensure high-quality, appropriate care.

• Offers leadership insights on opportunities for enhancing the level of care and medical necessity.

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

• Partners with care management on member referrals.

• Performs other assigned responsibilities.

⛳️ Requirements

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

• At least 2 years of experience in acute care nursing is required.

• 2–4 years of relevant experience is preferred.

• LPN - Licensed Practical Nurse - State Licensure is required.

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

• Preferred clinical knowledge and capability to assess the overall health of members, including treatment needs and suitable levels of care.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Previous experience in Utilization Management (UM) and/or Case Management (CM) is preferred.

• Must adhere to all policies and standards.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase plans.

• Tuition reimbursement programs.

• Paid time off in addition to holidays.

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

• Additional incentives may be part of the total compensation package.

• An equal opportunity employer dedicated to promoting diversity.