Clinical Review Nurse - Concurrent Review

Position Title : Clinical Review Nurse - Concurrent Review

Work Location : Remote - California, Must either reside in CA or hold a CA license, and work hours listed

Assignment Duration : 12 months (Extension & Contract-to-hire)

Work Schedule : Training 8 am-5 pm PST - about a month-long learning journey / Work schedule 8 am-5 pm PST

Work Arrangement : Remote

Responsibilities :

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

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

Preferred : Licensure

Required : California RN license ONLY

Preferred : Licensure

Preferred : Background with Centene highly preferred ; Trucare experience

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

Additional qualities to look for :

• Top 3 must-have hard skills stack-ranked by importance

Communication skills a must

FAST PACED, attention to detail, tech savvy

Interqual, one note, word, excel, teams,