Position Title: Clinical Review Nurse - Concurrent Review
Location: Remote
Duration: 12 Months
Schedule: Monday through Friday, 9:30 AM to 6:00 PM CST Position Summary 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.
Key Responsibilities
- Working within a highly engaged team remotely, with ongoing support to produce denial correspondence based off the advisor review that is in easy-to-understand language to the member and adheres to the NCQA and state standards. There may be at times, OT expectations based on business needs. This team does work holidays, which are rotated amongst the team members
- This team works together to support the day-to-day deadlines. This team works with the team culture of Service, Accountability, and Trust. This role is rewarding as it assists in ensuring the member understands why a service has been denied, which can then foster the relationship between the member and the provider.
Candidate Requirements Education/Experience: Required: Requires graduated from an accredited school of nursing or Bachelor's degree in nursing Required: LPN or RN,, Tx or Compact
Must haves: Minimum 1 year nursing experience.
Nice to haves: Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management Ability to critically think Ability to effectively use Microsoft OneNote and Word Ability to work remotely, i.e. meet production deadlines; quality metrics
