Clinical Review Nurse – Concurrent Review

Immediate need for a talented Clinical Review Nurse – Concurrent Review. This is a 06+months contract to hire opportunity with long-term potential and is located in TX(Remote). Please review the job description below and contact me ASAP if you are interested.

Job ID: 25-71195

Pay Range: $35 - $39/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Shift Time & Working Days: Mon-Fri 8ap-5pm CST
• 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.
• 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.
• Collects, 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.
• Assists with providing 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.
• Performs other duties as assigned.
• Complies with all policies and standards.
• Will have task queue to work from.
• Will work closely with team lead and team members to meet daily deadlines.
• Will be reviewing cases for medical necessity all day.
• Will work from home with multiple monitors and needs to be able to multitask.
• Once off training, they will need to work one Saturday every other month.
• Performance indicators: Quality work and meet productivity expectations

Key Requirements and Technology Experience:

• Key Skills; Concurrent Review
• Multitasking, fast learner, positive, and be computer savvy.
• 2+ Years as RN
• Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.
• 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.
• License/Certification: RN- Registered Nurse - State Licensure required.
• Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care.
• Graduate from an Accredited School of Nursing or bachelor’s degree in nursing Preferred: 2 – 4 years of related experience
• Licensure Required: Texas RN Preferred:
• Multitasking, fast learner, positive, and be computer savvy.
• Flexible, Ambetter knowledge
• Disqualifiers: Less than 2 years of nursing experience, no LPNs

Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

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