Clinical Review Nurse (RN) – Concurrent Review

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

Job ID:25-84726

Pay Range: $34 - $40/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, 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.
• 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:

• Skills-RN License, Concurrent Review and ADN or BSN
• TX RN license or compact state license
• Communication skills
• Documentation/Computer skills
• 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
• Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience. 2+ years of acute care experience required.
• 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.

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.
 
Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy .

#prof J2W:CB3