Clinical Review Nurse - Concurrent Review

Job Title: Clinical Review Nurse - Concurrent Review Duration: 12 months Contract (Possibility to extend or convert) Location: Remote - California Shift Type: 8am-5pm PST (Training 8am-5pm PST – about a month-long learning journey) payrate: $38-42/hr

Day to day responsibilities of this the role: • Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities • Productivity 17-20 reviews a day and quality expectations must be met • Partners with interdepartmental teams on projects within utilization management as part of the clinical review team • Partners and works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered • Assesses members and/or families for post discharge needs and provide education on discharge planning options based on diagnoses, prognoses, resources, and/or preferences • 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 • Manages and collaborates with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings • Provides education to providers on utilization processes to ensure high quality appropriate care to members • Partners with leadership to identify opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines • Oversees concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care • 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 • 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 • Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member • Oversees 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 • Provides subject matter expertise based on prior experience as well as training to other team members • Manages reporting to identify trends and provides recommendations to various teams • Performs other duties as assigned • Complies with all policies and standards

Skills Required: • 2 – 4 years of related experience - concurrent review / InterQual experience • TruCare experience. • One note, word, excel and teams

Education/Certification Required: • Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience. • California RN license