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Position Title: Clinical Review Nurse - Concurrent Review Work Location: Remote-Texas (do not have to reside in TX but would need a compact license that would with Texas) Assignment Duration: 6 months Work Schedule: 8am - 5pm CST Position Summary:
Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Background & Context:
* High volume, business needs to be compliant.
* Right now, the team is working to complete review
Should have a 10 -12 caseload per day, the team right now is handling a caseload of approximately 25 reviews per day, so they are seeking these roles for additional support.
* They will have a total of 3 screens (2 monitors) 1 laptop
* No wiggle room for deadlines - the team is needing these hires to be fast learners due to the support level needed on the team.
Key Responsibilities:
* Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
* Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
* Collaborates with care management on referral of members as appropriate
* Performs other duties as assigned
* Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
* Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
* Reviews member's overall health of member including treatment needs and appropriate level of care preferred.
* Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
* Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
* Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Qualification & Experience:
* Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
* Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
* Knowledge of Medicare and Medicaid regulations preferred.
* Knowledge of utilization management processes preferred.
* RN- Registered Nurse ? State Licensure required. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
* Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
* License/Certification: Required: Texas RN
* Must haves: Multitasking, fast learner, positive, and be computer savvy.
Must be able to work within multiple systems at once
Time management
* Nice to haves: Flexible, Ambetter knowledge
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Spectraforce Technologies
Sep 23, 2025