Nurse, Concurrent Review

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

📋 Description

• Conduct concurrent inpatient utilization reviews utilizing InterQual criteria to assess medical necessity.

• Execute admission, continued-stay, and transitional-care evaluations.

• Complete documentation updates and follow-up activities.

• Collaborate with attending physicians, hospitalists, and care teams to gather clinical information and aid in level-of-care decisions.

• Communicate clinical rationale during real-time concurrent review discussions.

• Facilitate the resolution of escalated cases and refer them to Physician Reviewers or Specialty Program Medical Directors.

• Support Physician Reviewers and Medical Directors in meeting compliance with review timeframes.

• Maintain written documentation according to HealthHelp policies.

• Implement regulatory, accreditation, payer-specific, InterQual, and HealthHelp/client medical policies.

• Follow HIPAA, state, and federal regulations, as well as URAC/NCQA standards.

• Act as a subject matter expert to support Compliance Department initiatives and updates.

• Collect and input confidential information.

• Conduct clinical intake and review expedited cases.

• Provide concurrent review coverage, including non-standard hours, weekends, and holidays when needed.

• Identify and refer quality issues to UM Leadership.

• Work with client personnel to address customer concerns.

• Deliver quality customer service to providers, administrative staff, and others.

• Engage in the HealthHelp Quality Management Program.

• Perform additional related duties and projects as assigned.

⛳️ Requirements

• RN graduate from an accredited nursing school (BSN preferred).

• Current, active, unrestricted RN license in the U.S. state or territory (USRN equivalent).

• Minimum of two (2) years of experience in an acute care environment, required.

• At least two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred.

• Experience with InterQual or similar evidence-based clinical decision support criteria, preferred.

• Willingness to complete and maintain InterQual certification and ongoing competency requirements.

• Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred.

• Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements.

• Understanding of insurance terminology.

• Experience with state and federal regulatory and compliance standards, preferred.

• Proficient in Microsoft Office (Word, Excel, and PowerPoint), required.

• Strong organizational and time management abilities.

• Excellent written and verbal communication skills.

• Capacity to apply critical thinking skills.

• Highly motivated self-starter capable of working efficiently and independently, or as part of a team.

• Availability to work weekends or alternative daytime hours based on business needs.

• 100% attendance is required for the first 90 days.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off (PTO), holidays, and sick leave.

• 401(k) with company match or other retirement plans.

• Life and AD&D Insurance.

• Employee Assistance Program.

• Performance-based bonuses, incentive pay, or commissions may be available.

• Equipment provided (mini desktop, dual monitors, mouse, keyboard, headset).