New 
Clinical Review Nurse - Concurrent Review
 Spectraforce Technologies | ||||||||||||||||
 United States, Illinois, Chicago | ||||||||||||||||
 Dec 02, 2025 | ||||||||||||||||
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Position Title: Clinical Review Nurse - Concurrent Review
Work Location: Remote - National; must work CST hours Assignment Duration: 12 months Work Schedule: Wednesday-Saturday 8am-6:30pm CST Work Arrangement: Remote (not field based) 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. Background & Context: Supporting Illinois and Michigan health plans within Shared Services. Purpose of team is ensuring members and requesting providers receive written documentation of denied services. Key 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
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