Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent reviews to assess members’ overall health, appropriate care, and care levels.

• Analyze the type, quality, continuity, acuity, resource usage, duration of stay, and environment of care.

• Assess medical necessity and assist in discharge planning.

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

• Gather, document, and maintain review outcomes, discharge plans, and actions within health management systems.

• Partner with healthcare providers to validate medical determinations or offer recommendations.

• Educate providers on utilization processes.

• Provide leadership insights on opportunities to enhance care levels and medical necessity.

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

• Work together with care management on member referrals.

• Adhere to all policies and standards.

• Execute additional duties as assigned.

⛳️ Requirements

• This is a remote position; PA or Compact License is required.

• Working hours are Monday to Friday, from 8 AM to 5 PM.

• Must be a graduate from an Accredited School of Nursing or hold a Bachelor’s degree in Nursing.

• Requires 2–4 years of relevant experience.

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

• Must possess RN – Registered Nurse – State Licensure and/or Compact State Licensure.

• Preferred clinical knowledge to evaluate overall health, treatment requirements, and suitable care levels.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Prior experience in Case Management or UM/UR is highly preferred.

• Experience with MCG or InterQual is advantageous.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Opportunities for stock purchase.

• Tuition reimbursement for further education.

• 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.

• Commitment to equal opportunity employment.