Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent evaluations to assess members’ overall health, appropriateness of care, medical necessity, and the suitable level or setting of care.

• Analyze acuity levels, resource utilization, length of stay, and discharge planning.

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

• Gather, document, and sustain review outcomes, 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 insights on opportunities for enhancing levels of care and medical necessity.

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

• Work in conjunction with care management on member referrals.

• Adhere to policies and standards while performing other assigned tasks.

⛳️ Requirements

• A Texas RN or Compact License is mandatory.

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

• 2–4 years of relevant experience is required.

• More than 2 years of acute care experience is necessary.

• 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 requirements and appropriate levels of care.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is advantageous.

• Availability Monday–Friday from 8 AM to 5 PM CST, with one weekend per month required.

• Experience in ICU or ER is preferred.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement assistance.

• Paid time off along with holidays.

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

• Additional forms of incentives may be included in total compensation.

• Equal opportunity employer dedicated to promoting diversity.