Clinical Review Nurse - Concurrent Review

Position Title: Clinical Review Nurse - Concurrent Review

Work Location: Remote - CA

Assignment Duration: 12 months with possibility of extension

Work Schedule: 8am-5pm PST

Training Schedule: 8am-5pm PST - about a month long learning journey - CAMERAS ON - NO TIME OFF

Job description:

• 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.