Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent reviews, which involve assessing members’ overall health, analyzing the care provided, evaluating medical necessity, and assisting with discharge planning.

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

• Determine the suitable care and level of care in accordance with members’ overall health status.

• Review the quality and continuity of care, acuity levels, resource utilization, length of stay, and discharge planning.

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

• Gather, document, and maintain findings from concurrent reviews, discharge plans, and actions taken within medical records and health management systems.

• Partner with healthcare providers to approve medical determinations or offer recommendations based on requested services and review outcomes.

• Educate providers about utilization processes.

• Provide leadership insights on enhancing levels of care and medical necessity.

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

• Work in conjunction with care management on member referrals.

• Adhere to all policies and standards while performing other assigned duties.

⛳️ Requirements

• Graduate from an accredited nursing program 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.

• Texas RN or Compact License is required.

• LPN state licensure is required.

• RN state licensure and/or Compact State Licensure is necessary.

• Preferred clinical knowledge and capability to assess a member's overall health, including treatment requirements and appropriate care levels.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Knowledge of utilization management processes is preferred.

• ICU or ER experience is preferred.

• Availability for Monday–Friday from 8 AM to 5 PM CST and one weekend per month is required.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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

• Competitive salary.

• Additional incentives may be included in total compensation.