Clinical Review Nurse - Concurrent Review

Summary:

• Work Mode: 100% Remote
• Duration: 6 months, possible extension
• Shift: Sunday, Monday, Tuesday, Wednesday OR Wednesday, Thursday, Friday, Saturday
• Work hours: 7am - 6pm EST

Responsibilities:

• Perform 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.
• Review quality and continuity of care by assessing acuity level, resource consumption, length of stay, and discharge planning of members.
• Collaborate with Medical Affairs and/or Medical Directors to discuss member care being delivered.
• Collect, document, and maintain concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines.
• Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
• Assist with providing education to providers on utilization processes to ensure high-quality, appropriate care to members.
• Provide feedback to leadership on opportunities to improve appropriate level of care and medical necessity based on clinical policies and guidelines.
• Review member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collaborate with care management on referral of members as appropriate.
• Promote the quality and cost-effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.
• Perform other duties as assigned. PERFORMANCE EXPECTATIONS: 95% weighted productivity, 2.1 reviews per hour (14 per day), 90% audit scores, and 100% TAT.

Requirements:

• Graduate from an Accredited School of Nursing.
• Nursing License with state of Georgia or Compact licensure.
• Minimum 2 years of acute care experience required.
• Concurrent Review Utilization Management Experience in a Medicaid/Marketplace health plan.
• Experience with Interqual.
• Knowledge of healthcare and managed care.

Preferred Skills:

• BSN/CCM.
• Compact licensure preferred.
• Computer skills (Word, Excel, Interqual experience).
• Experience with reading Electronic Medical Records.
• Good written and verbal communication skills.
• Team player, calm under stress, motivated, and able to multi-task.