Clinical Review Nurse - Concurrent Review TX

Overview

Clinical Review Nurse - Concurrent Review TX

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.

• Perform concurrent reviews of member care to determine medical necessity and setting of care, and assess overall health.
• 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 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 transfer or discharge plans to ensure timely discharge between levels of care and facilities.
• Collaborate with care management on referral of members as appropriate.

• Education/Certification
  
  Required:
  
  Graduate from an Accredited School of Nursing or bachelor’s degree in nursing.
• Licensure
  
  Required:
  
  Texas RN.
• Preferred Experience:
  
  2 – 4 years of related experience; 4 years is preferred.
• Years of experience: UM experience preferred but not required.
• Disqualifiers:
  Less than 2 years of nursing experience, no LPNs.
• Additional qualities:
  Multitasking, fast learner, positive, and computer savvy.