Remote New 
Clinical - Clinical Review Nurse - Concurrent Review - J00933
 Spectraforce Technologies | |
 United States, North Carolina, Raleigh | |
| 500 West Peace Street (Show on map) | |
 Nov 13, 2026 | |
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Job Profile Summary
Position Purpose: Performs concurrent reviews, including determining members 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. EducationExperience: Requires Graduate from an Accredited School of Nursing or Bachelors degree in Nursing and 2 4 years of related experience. 2 years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. LicenseCertification: LPN Licensed Practical Nurse State Licensure required For Health Net of California: RN license required 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 andor 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 members 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 Release Comments: shortlisting on 1117 Please use the below link to begin submitting Candidates. https:prod.beeline.comcentene0b58a05e4a5f4be3bedc8349edbe2ee4 This email has been generated to notify you of account activity that has occurred within the Beeline application. Please review the details above for necessary action on your part, or click on the link provided to login to the application to review the activity. Please do not reply to this email. If you need assistance, please contact application support at 1866Beeline or supportbeeline.com. | |