Clinical Review Nurse - Concurrent Review - J00933

Remote Position - Location does not require to be in Corpus Christi, TX. Preferably in Central Standard time, but not required. Must have Texas RN License.

Duration : 6months

Schedule : Sunday to Thursday 8am to 5pm CST

Position Purpose :

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. 2+ years of acute care experience required.

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.

Responsibilities

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

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

• Conduct clinical reviews to assess medical necessity and continued stay criteria. Document findings accurately and timely in our review system. Communicate with hospital case managers, providers, and internal teams to coordinate care and discharge planning. Respond to escalations or requests for additional information from utilization management or quality teams. Track and prioritize cases to ensure compliance with turnaround standards.

Work environment is collaborative, supportive, and focused on teamwork. We rely on clear communication and trust to manage complex revies and maintain consistency. While the work can be fast-paced, the team prioritizes mutual support and professional growth.

Candidate Requirements

Education / Certification

Required : ADN or BSN

Preferred : Licensure

Required : RN

Preferred : Licensure

Must haves : 3-5 years Acute Clinical experience. Ie : ER, ICU, IMC

Nice to haves : Concurrent Review experience

Disqualifiers :

Performance indicators :

Clinical Experience / Bedside nursing experience at minimum 3 years.

Technologically inclined

Organizational skills and prioritization skills, critical thinking skills