Job Profile Summary
Position Purpose:
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.
Education/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.
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
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
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Position Purpose:
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.
Education/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.
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
Story Behind the Need
- What is the purpose of this team?
- What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
The Utilization Management team review members who are currently receiving inpatient services to ensure that care remains medically necessary, appropriate, and provided at the correct level of care. The review nurse assesses the member’s clinical status, perform continued stay reviews, facilitate discharge planning and promote timely, appropriate care.
The need is driven by needing to backfill FTE positions. There are no upcoming hiring needs and this is not a part of a larger hiring initiative.
Typical Day in the Role
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
The concurrent review nurse spends the day performing medical necessity reviews of inpatient admissions and continued stays apply clinical criteria and guidelines such as InterQual, internal clinical policies and plan specific requirements. The nurse also communicates with hospitals, review clinical documentation, making authorization determinations within nursing scope, identifying discharge planning needs and barriers, collaborate with case management and other staff as well as other duties.
The CCR nurse is required to process 2.2 reviews per hour (14-16 reviews daily).
Concurrent Review Nurses perform a highly specialized function that combines medical necessity review, inpatient utilization management, discharge planning, transition-of-care coordination, and provider collaboration. The role requires continuous clinical assessment throughout a member's hospitalization, proactive identification of discharge barriers, coordination of post-acute services, and close collaboration with providers, Medical Directors, and Care Management teams to ensure appropriate utilization, regulatory compliance, safe transitions of care, reduced length of stay, and prevention of avoidable readmissions.
Candidate Requirements
Education/Certification
Required: Associate degree
Preferred: Bachelor
Licensure
Required: Registered Nurse License (MS or Compact)
Preferred: RN License
Years of experience required: 2 years
Disqualifiers: LPN
Additional qualities to look for: Flexible, Results oriented
- Top 3 must-have hard skills stack-ranked by importance
1
Basic Computer Knowledge
2
Critical Thinking Skills
3
Time Management/Organized
Candidate Review & Selection
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
Projected Manager Candidate Review Date:
1-2 days post shortlisting
Type of Interviews:
Teams, phone, etc.
Required Testing or Assessment (by Vendor):
n/a
Next Steps
- Do you have any upcoming PTO?
None
- Colleagues to cc/delegate
Angela Brown, Senior Manager
