Clinical Review Nurse - Concurrent Review
Job Title: Clinical Review Nurse - Concurrent Review
Location: Remote CA
Duration: 5 Months (Possible extension)
Schedule: Monday through Friday 8am to 5 pm (PST)
Description:
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.
Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred.
License/Certification:
LPN - Licensed Practical Nurse - State Licensure required.
Responsibilities:
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. Performs other duties as assigned. Complies with all policies and standards.
Required Skills/Experience:
1. Computer Skills - Microsoft, Teams, Zoom
2. Good communication skills for clinical rounds
3. 2-4 years of hospital, managed care, UM experience
Education Requirement:
Graduate from an accredited School of Nursing
Education Preferred:
ASN or BSN
Software Skills Required:
Microsoft, basic computer knowledge with electronic medical record programs
Required Certifications:
California Registered Nurse
Required Testing:
InterQual Interrater Reliability Testing
#J-18808-Ljbffr
