Clinical Review Nurse - Concurrent Review

Position Purpose

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.

Key Details

• The position is remote/work from home; applicants must hold an IL RN licensure.
• The position is supporting Utilization Management/Concurrent Review for the YouthCare program.
• The position supports inpatient only, and will be cross trained for Prior Authorization.
• The work schedule is Monday - Friday 8am - 5pm central time zone; after successfully completing training could work a flex schedule.

Education/Experience

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
• 2+ years of acute care experience required.
• 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.

Pay Range

Pay Range: $27.02 - $48.55 per hour

About the Role

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
Collections, 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
Provides 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

Skills

Complies with all policies and standards.

Benefits

Competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.

Schedule

Monday - Friday 8am - 5pm central time zone; after successfully completing training could work a flex schedule.