Clinical Review Nurse – Concurrent Review

Immediate need for a talented Clinical Review Nurse – Concurrent Review. This is a 06+months contract to hire opportunity with long-term potential and is located in TX(Remote). Please review the job description below and contact me ASAP if you are interested.

Shift Time & Working Days: Mon-Fri 8ap-5pm CST 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. 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 delivered. 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. 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 appropriate. Performs other duties as assigned. Complies with all policies and standards. Will have task queue to work from. Will work closely with team lead and team members to meet daily deadlines. Will be reviewing cases for medical necessity all day. Will work from home with multiple monitors and needs to be able to multitask. Once off training, they will need to work one Saturday every other month. Performance indicators: Quality work and meet productivity expectations