Clinical Review Nurse - Concurrent Review

Clinical Review Nurse – Concurrent Review

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
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

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