Clinical Review Nurse - Concurrent Review - J00933
 Spectraforce Technologies | ||||||||||||||||
 United States, California, Los Angeles | ||||||||||||||||
 Sep 11, 2025 | ||||||||||||||||
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Position Title: Clinical Review Nurse - Prior Authorization 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
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