Concurrent Review Nurse
Position Summary
The Concurrent Review Nurse is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements.
Key Responsibilities
Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care
Evaluate clinical documentation against evidence-based criteria (e.g., InterQual®, MCG) to determine medical necessity and appropriate level of care
Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning
Communicate utilization review decisions and recommendations to providers and payers
Document all reviews, decisions, and communications in accordance with regulatory and organizational standards
Identify cases requiring escalation or peer review and follow established procedures
Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA
Participate in quality improvement initiatives and departmental meetings
Qualifications
Education & Licensure: Registered Nurse (RN) license, active and in good standing, required
Associate or Bachelor’s degree in nursing (BSN preferred)
Experience: Minimum 2 years of clinical experience (e.g., med-surg, critical care)
At least 1 year of utilization review, case management, or managed care experience preferred
Skills & Competencies: Knowledge of InterQual®, MCG, or other clinical review guidelines
Familiarity with Medicare/Medicaid and commercial insurance regulations
Strong analytical and clinical judgment skills
Effective communication and negotiation skills
Proficient with electronic medical records (EMRs) and utilization review platforms
Detail-oriented with excellent organizational skills