Clinical - Clinical Review Nurse - Concurrent Review - J00933

Location : Remote - California, Must either reside in CA or hold a CA license and work hours. California RN license ONLY

SHIFT : Training 8am-5pm PST about a month long learning journey CAMERAS ON NO TIME OFF for first 90 days.1 Actual Work schedule 8am-5pm PST Mon - Fri

Duration : 12 months, possible extension or conversion

Tentative Start date : 10 / 20 / 2025

Job Description : We have an opportunity to meet Quality Assurance with each case as every decision made helps ensure members receive the right care at the right time, while also supporting cost-effective healthcare delivery.

You ll work alongside experienced clinicians, analysts, and operations professionals who are passionate about healthcare and committed to excellence.

Leadership is focused on clarity, accountability, and growth. You ll have clear expectations, regular feedback, and opportunities to contribute to strategic initiatives.

Typical Day in the Role :

o Reviews member s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.

o Productivity 17-20 reviews a day and quality expectations must be met.

o Partners with interdepartmental teams on projects within utilization management as part of the clinical review team

o Partners and works with Medical Affairs and / or Medical Directors as needed to discuss member care being delivered

o Assesses members and / or families for post discharge needs and provide education on discharge planning options based on diagnoses, prognoses, resources, and / or preferences

o Manages 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

o Manages and collaborates with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings

o Provides education to providers on utilization processes to ensure high quality appropriate care to members

o Partners with leadership to identify opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines

o Oversees concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care

o Provides insight and guidance on concurrent reviews to determine overall health of member, review the type of care being delivered to member, and approving treatment needs including discharge planning

o Provides guidance and expert knowledge, as appropriate, to utilization management team to address issues and validate the necessity and setting of care being delivered to the member

o Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member

o Oversees member s transfer or discharge plans to ensure a timely discharge between levels of care and facilities

o Collaborates with care management on referral of members as appropriate

o Provides subject matter expertise based on prior experience as well as training to other team members

o Manages reporting to identify trends and provides recommendations to various teams

o Performs other duties as assigned

o Complies with all policies and standards

Years of experience required : 2 4 years of related experience - concurrent review / interqual experience

Preferred : Background with client highly preferred ; Trucare experience

Disqualifiers : unmotivated, inability to work autonomously, no time off for first 90 days ,

Pay Rate : $40- 44 / hr depending on experience

Candidate Requirements

Education / Certification

ADN or above

Requires Graduate from an Accredited School of Nursing or Bachelor s degree in Nursing and 2 4 years of related experience

Licensure

Required : California RN license ONLY