Clinical Review Nurse – Concurrent Review

Clinical Review Nurse – Concurrent Review

Requirements

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
• 2 – 4 years of related experience
• 2+ years of acute care experience required
• LPN – Licensed Practical Nurse – State Licensure required

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

Preferred Qualifications

• 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