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.
• Referred cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines.
• Aids Physician Reviewers and Medical Directors, as necessary, 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 collaborative environment that promotes teamwork, respect, diversity, and cooperation with others.
• Promotes business focus demonstrating 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
• Ability to utilize 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
• 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
• Ability to utilize 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
• Medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements
• Insurance terminology
• Microsoft Office (Word, Excel, and PowerPoint)
• Organizational and time management skills
• Written and verbal communication skills
• Critical thinking skills

Benefits

Our benefits package includes (but is not limited to): Medical, dental, and vision insurance, Paid time off (PTO), holidays, and sick leave, 401(k) with company match or other retirement plan, Life and AD&D Insurance, Employee Assistance Program.

Pay

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. In addition to base pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed base salary range.

Schedule

7AM – 5PM PST / 9AM – 7PM CST Monday- Friday while you should remain flexible based on business needs.

Additional Information

Note: For complete compensation information, please refer to the job posting on our official careers page.