Clinical Review Nurse - Concurrent Review TX

Clinical Review Nurse - Concurrent Review TX
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Job Description

Location: 100% Remote - TX: RN only with TX license

SHIFT: Tuesday – Saturday 8am-5pm CST- schedule is firm- no flexibility

Duration: 6 months, contract to hire.

Job Purpose: This is a fast-paced role. The nurse will be reviewing clinical faxed in by facilities for medical necessity. The nurse gains valuable regarding commercial insurance. 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.

Typical Day in the Role:
8am-5pm CST, Tues - Saturday. Will have task queue to work from. Will work closely with team lead and team members to meet daily deadlines. Will be reviewing cases for medical necessity all day. Will work from home with multiple monitors and needs to be able to multitask. Once off training, they will need to work one Saturday every other month.
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.
Candidate Requirements
Education/Certification    Required: Graduate from an Accredited School of Nursing or bachelor’s degree in nursing    Preferred: 2 – 4 years of related experience- 4 years is preferred
Licensure    Required: Texas RN    Preferred:
Years of experience required: UM experience preferred not required

Disqualifiers: Less than 2 years of nursing experience, no LPNs

Additional qualities to look for: Multitasking, fast learner, positive, and be computer savvy.