Job Title:
Clinical Review Nurse - Concurrent Review
Duration:
06 months in W2 - Possibility to extend or Convert
Location:
Remote-GA
Schedule:
Sunday, - Wed or Wednesday - Sat - Min OT when needed. 7a-6p EST
Payrate: $40-42/hr
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. PERFORMANCE EXPECTATIONS: 95% weighted productivity, 2.1 reviews per hour (14 per day), 90% audit scores and 100% TAT.
This position is fully remote
Requirements:
Can be located outside GA but must have compact license & willing to work EST hours
2+ years of acute care experience required.
Concurrent Review Utilization Management Experience in a Medicaid/Marketplace health plan.
Experience with InterQual.
Knowledge of healthcare and managed care.
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.