Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conducts concurrent reviews, which include assessing a member's overall health, evaluating the type of care being provided, determining medical necessity, and contributing to discharge planning in accordance with care policies and guidelines.

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

• Performs concurrent reviews for members to ensure appropriate care and setting, determining overall health and suitable level of care.

• Reviews the quality and continuity of care by analyzing acuity levels, resource usage, length of stay, and discharge plans for members.

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

• Gathers, documents, and preserves findings from concurrent reviews, discharge plans, and actions taken within member medical records in health management systems, adhering to utilization management policies and guidelines.

• Works alongside healthcare providers to approve medical determinations or offer recommendations based on requested services and concurrent review outcomes.

• Assists in educating providers on utilization processes to ensure that members receive high-quality, appropriate care.

• Provides leadership with feedback on opportunities to enhance the appropriate level of care and medical necessity in line with clinical policies and guidelines.

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

• Collaborates with care management on member referrals as appropriate.

• Performs additional tasks as assigned.

• Adheres to all policies and standards.

⛳️ Requirements

• A compact RN licensure is preferred, along with a minimum of 2 years of acute care clinical experience.

• Must be available to work eastern time zone hours, either Tuesday - Saturday or Sunday - Thursday, with rotational holidays (approximately 3 per year).

• Preferred knowledge of Utilization Management as well as Medicare and Medicaid regulations.

• Requires graduation from an Accredited School of Nursing or a Bachelor’s degree in Nursing, accompanied by 2 – 4 years of relevant experience.

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

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

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

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

• RN - Registered Nurse - State Licensure and/or Compact State Licensure for the State of Nevada is required.

• No travel is required.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work options with remote, hybrid, field, or office schedules.

• Additional forms of incentives.

• Benefits may be subject to program eligibility.