Nurse, Concurrent Review

About the role

Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including: Admission reviews, Continued stay reviews, Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital) and related follow-up activities and documentation updates.

Responsibilities

• Engages in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions.
• Communicates clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions.
• Facilitates resolution of escalated cases that may require special handling.
• Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines.
• Affixes to ensure compliance with review timeframes.
• Maintains written documentation according to HealthHelp’s documentation policy.
• Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations.
• Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs.
• Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management.
• Functions as subject matter expert to support Compliance Department initiatives and updates.
• Collects and enters confidential information ensuring the highest level of confidentiality in all areas.
• Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times.
• Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes.
• Performs multiple tasks simultaneously, prioritizes projects, works independently under pressure, and meets critical deadlines.
• Identifies and refers quality issues to UM Leadership.
• Collaborates with client personnel to resolve customer concerns.
• Provides quality customer service through interaction with providers, administrative staff, and others.
• Fosters a supportive environment that promotes teamwork, respect, diversity, and cooperation with others.
• Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy.
• Participates in the HealthHelp Quality Management Program, as required.
• Performs other related duties and projects as assigned to meet business needs.

Requirements

• RN graduate from an accredited school of nursing (BSN preferred).
• Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent).
• Two (2) years of experience in an acute care setting, required.
• Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred.
• Experience with InterQual or similar evidence-based clinical decision support criteria, preferred.
• Willingness to complete and maintain InterQual certification and ongoing competency requirements.
• Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred.
• Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements.
• Knowledge of insurance terminology.
• Experience working with state and federal regulatory and compliance standards, preferred.
• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required.
• Good organizational and time management skills.
• Excellent written and verbal communication skills.
• Utilizes critical thinking skills.
• Highly motivated, self-starter who can work efficiently and independently, or as a team member.

Qualifications

• Willingness to complete and maintain InterQual certification and ongoing competency requirements.
• Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred.
• Knowledge of insurance terminology.
• Experience working with state and federal regulatory and compliance standards, preferred.
• Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required.
• Good organizational and time management skills.
• Excellent written and verbal communication skills.
• Utilizes critical thinking skills.
• Highly motivated, self-starter who can work efficiently and independently, or as a team member.

Skills

• InterQual or similar evidence-based clinical decision support criteria.
• Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning.
• Medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements.
• Insurance terminology.
• State and federal regulatory and compliance standards.
• Microsoft Office (Word, Excel, and PowerPoint) proficiency.
• Organizational and time management skills.
• Written and verbal communication skills.
• Critical thinking skills.

Benefits

The base salary for this position is $75,000 annually. This represents the base pay range that we reasonably expect to offer for this position. Final compensation will be determined based on a variety of factors, including but not limited to the candidate’s experience, education, skillset, and location. Geographic location, overall professional experience, directly relevant experience, education and certifications, industry knowledge and expertise, and skills and competencies are considered in determining final compensation.

Pay

$75,000 annually

Schedule

Remote