Clinical Review Nurse - Concurrent Review

Immediate need for a talented Clinical Review Nurse - Concurrent Review. This is a 06+months contract 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: 25-78309

Pay Range: $33 - $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:

• 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.
• The nurse will be reviewing about 20 cases a day to review for medical necessity on a member that admits to the hospital. Job is to advocate and protect the member from unnecessary admissions to the hospitals.
• Nurse must follow many changes and processes to complete the authorizations.
• Will be working with a group of nurses to assist each other and collaborate on getting the cases done.
• The nurse will be in contact with doctors and case managers to achieve decisions and/or receive more information about the member’s condition/status.
• Nurse will be using multiple resources we have to achieve successful completion of the cases.

Key Requirements and Technology Experience: 

• Key Skills; TX RN license or compact state license.
• UM- Concurrent Review
• Hospital 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.
• Education/Certification Required: RN
• Must haves: 2-4 years of hospital experience, multi-tasking, time management, quick learner, go with the flow attitude, computer savvy.
• Nice to haves: UM, Clinical/managed care experience
• Disqualifiers: unable to multitask, disorganized, not willing to make calls, not computer savvy.
• Performance indicators: Will be monitoring productivity daily.
• Communication skills.
• Documentation/Computer skills.

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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