Concurrent Review Nurse

About the role

The CRN is responsible for performing medical reviews using established criteria to ensure the member is receiving care at the most appropriate level. The CRN builds relationships with facility case managers to facilitate appropriate care and discharge planning. The CRN is responsible for identifying appropriate care programs for members to ensure a smooth transition from facility to home and to decrease frequency of readmission.

Responsibilities

• Serve as a point of contact for providers to assist in navigating members through the continuum, educate regarding benefits, identify candidates for Care Programs and provide information pertaining to the network and network access
• Evaluate members in the Hospital, Skilled Nursing Facility, LTAC, Acute Inpatient Rehab for benefit determination, medical necessity and appropriate level of care utilizing member benefits and InterQual or other medical necessity criteria
• Participate in weekly case review
• Determine member's discharge status and identify and coordinate any additional needs and services that require ongoing Care Coordination services
• Collaborate with Medical Directors, Managers, Co-workers and other departments including Case Management and Care Partners
• Other duties as assigned

Requirements

• 2+ years related work experience. Experience Details: Recent (within the past 3-5 years) clinical experience in a hospital, LTAC, Rehab, SNF setting evaluating hospital benefit determination, medical necessity and appropriate level of care
• Related Bachelor’s degree or additional related equivalent work experience
• Nursing Registered Nurse - State Licensure And/Or Compact State Licensure
• Florida Experience in one or more of the following: home health care, rehab, SNF, utilization review, discharge planning or case management
• Referrals for possible Case Management activities that focus on acute and non-acute services, outpatient services and/or community resources
• Experience with the Healthcare industry and Managed Care
• Experience in MS Word and Excel
• Moderate to heavy keying required
• Occasional travel within the State of Florida

Preferred

• Bachelor’s degree Nursing, Healthcare or Business
• Registered Nurse - State Licensure and/or Compact State Licensure Florida
• Unrestricted US RN license
• Utilization Review/Management