Clinical Review Nurse - Concurrent Review

Summary:

• Work Mode: Remote – anywhere working for Oklahoma in CST
• Duration: 3 months with possible extension
• Schedule: 8-5 weekend rotation (every 4-6 weeks)

Responsibilities:

• Perform concurrent reviews to determine member's overall health and appropriate level of care.
• Review quality and continuity of care by evaluating acuity level, resource consumption, length of stay, and discharge planning.
• Collaborate with Medical Affairs and/or Medical Directors as needed to discuss member care.
• Collect, document, and maintain concurrent review findings, discharge plans, and actions in health management systems.
• Work with healthcare providers to approve medical determinations or provide recommendations.
• Provide education to providers on utilization processes to ensure high-quality care.
• Provide feedback to leadership on opportunities to improve care level and medical necessity.
• Review member’s transfer or discharge plans to ensure timely discharge between levels of care and facilities.
• Collaborate with care management on member referrals as appropriate.
• Perform clinical medical necessity review with an expectation of 14 reviews per day.
• Comply with all policies and standards.

Requirements:

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• Licensed nurse in the state of Oklahoma.
• Minimum 2 years of acute care experience.

Preferred Skills:

• Clinical knowledge and ability to determine overall health of members.
• Knowledge of Medicare and Medicaid regulations.
• Knowledge of utilization management processes.
• Ability to work autonomously.
• Fast learner with the ability to research for knowledge.
• Task-oriented.