Clinical Review Nurse – Concurrent Review

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

📋 Description

• Conduct concurrent reviews to assess members’ overall health, evaluate the care provided, assess medical necessity, and assist in discharge planning.

• Analyze inpatient services to confirm the necessity and appropriateness of the care received.

• Identify suitable care levels and types based on member health status, acuity, 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 within health management systems.

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

• Educate providers on utilization management processes.

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

• Review transfer and discharge plans to ensure efficient transitions.

• Work together with care management on member referrals.

• Adhere to all policies and standards; perform other assigned duties.

⛳️ Requirements

• Texas RN or Compact License is mandatory.

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

• Required 2–4 years of relevant experience.

• At least 2 years of acute care experience is essential.

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

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

• Clinical knowledge with the ability to assess members' overall health, including treatment requirements and appropriate care levels, is preferred.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• Experience in ICU or ER settings is preferred.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off along with holidays.

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

• Potential for additional forms of incentives.