Clinical Review Nurse – Concurrent Review, NICU

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

📋 Description

• Conduct concurrent reviews to assess members’ overall health, appropriate care, and required level of care.

• Evaluate the quality and continuity of care, acuity level, resource utilization, length of stay, and discharge planning processes.

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

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

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

• Inform providers about utilization processes.

• Provide leadership with feedback on opportunities to enhance appropriateness of care levels and medical necessity.

• Review member transfer or discharge plans to guarantee timely discharges between various levels of care and facilities.

• Work in conjunction with care management on member referrals.

• Assist Medicaid and Ambetter/marketplace insurance members.

• Adhere to all policies and standards.

• Execute additional responsibilities as assigned.

⛳️ Requirements

• Graduate from an accredited nursing school or possess a Bachelor’s degree in Nursing.

• Minimum of 3 years of level III or IV NICU experience.

• At least 2 years of acute care experience.

• LPN state licensure is required.

• RN state licensure and/or compact state licensure for the State of Nevada is mandatory.

• Capability to obtain licensures in non-compact states.

• Clinical expertise and the ability to assess the overall health of members, including their treatment needs and appropriate level of care, are preferred.

• Familiarity with Medicare and Medicaid regulations is preferred.

• Understanding of utilization management processes is preferred.

• NICU certification is advantageous.

• Preference will be given to applicants residing in either central or eastern time zones.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase plans.

• Tuition reimbursement opportunities.

• Paid time off along with holidays.

• Flexible working arrangements with options for remote, hybrid, field, or office schedules.

• Reimbursement for costs associated with obtaining licensure in non-compact states.