Remote Concurrent Review Nurse

The Concurrent Review Nurse plays a vital role in ensuring that members receive the appropriate level of care by conducting concurrent reviews, evaluating medical necessity, and contributing to discharge planning according to established care policies and guidelines.

The Concurrent Review Nurse plays a vital role in ensuring that members receive the appropriate level of care by conducting concurrent reviews, evaluating medical necessity, and contributing to discharge planning according to established care policies and guidelines.

• Conduct concurrent reviews of members to determine the appropriateness of care and setting, assessing overall health and care levels.
• Review and ensure the quality and continuity of care by analyzing acuity level, resource consumption, length of stay, and discharge planning.
• Collaborate with Medical Affairs and/or Medical Directors to discuss member care and provide necessary recommendations.
• Document and maintain findings, discharge plans, and actions taken in health management systems according to utilization management policies.
• Work closely with healthcare providers to approve medical determinations or provide recommendations based on concurrent review findings.
• Educate providers on utilization processes to ensure high-quality care delivery to members.
• Provide feedback to leadership on improving care levels and medical necessity based on clinical policies.
• Ensure timely transitions of care between levels of care and facilities by reviewing transfer or discharge plans.
• Collaborate with care management teams on appropriate member referrals.
• Perform other duties as assigned while complying with all policies and standards.

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
• 2-4 years of related experience, including 2+ years of acute care experience.
• Clinical knowledge to assess overall health and treatment needs.
• Knowledge of Medicare and Medicaid regulations.
• Understanding of utilization management processes.
• State Licensure as a Licensed Practical Nurse or RN license for Health Net of California.
• Ability to apply Inter Qual, MCG, and established utilization management criteria to support review decisions.

• Experience with conducting concurrent reviews of inpatient hospital and post-acute care cases.
• Proficiency in evaluating clinical documentation, treatment plans, and resource utilization.
• Experience with documenting findings in Tru Care Classic and Tru Care Cloud.
• Ability to facilitate care transitions and provide recommendations on medical necessity.
• Skills in educating providers on utilization management processes and clinical guidelines.
• Problem-solving and triage skills related to utilization review cases.
• Compliance with organizational, state, federal, Medicare, and Medicaid regulations.

The position requires working within a healthcare setting, collaborating with a diverse team of healthcare professionals, including physicians, providers, and care management teams. The role involves utilizing technologies such as Tru Care Classic and Tru Care Cloud to document and support review decisions. The work environment supports professional growth and collaboration, adhering to high standards of care and regulatory compliance.

This is a Contract to Hire position based out of Texas City, TX.

The pay range for this position is $38.00 - $42.00/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibil…