Clinical Review Nurse - Concurrent Review

Position Title: Clinical Review Nurse- Concurrent Review

Work Location: Remote- Georgia (Eastern Standard Time)

can work EST

Work Schedule: Sunday, - Wed

Wednesday - Sat

Min OT when needed.

7a-6p EST

Assignment Duration: 6 months with possible extention

Work Arrangement: This position is fully remote.

Position Summary: 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

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
• Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.
• Performs other duties as assigned.