Clinical Review Nurse - Concurrent Review

Position Title: Clinical Review Nurse - Concurrent Review

Work Location: Texas (do not have to reside in TX but would need a compact license for Texas)

Assignment Duration: 6 months (Possibility to convert)

Work Schedule: 8am-5pm CST

Work Arrangement: Remote

They would be working Saturday & Sunday - they would then pick their two consecutive days they do not want to work (Monday, Tuesday) (Tuesday, Wednesday) (Thursday, Friday) working remainder of the week

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. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

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:

• 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
• Works with Medical Affairs and/or Medical Directors as needed to discuss member care being deliveredCollects, 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
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
• Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
• Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
• Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Collaborates with care management on referral of members as appropriatePerforms other duties as assignedComplies with all policies and standards

Qualification & Experience:

• Required: Graduate from an Accredited School of Nursing or bachelor's degree in nursing
• Preferred: 2 - 4 years of related experience
• Required: Texas RN