Clinical Review Nurse - Concurrent Review

Position Title: Clinical Review Nurse - Concurrent Review

Work Location: Remote - LA

(Can reside anywhere within the US as long as they have a compact license and support the LA time zone)

Assignment Duration: 12 months.

Work Schedule: 10-7 CST; 1 will work Tuesday - Saturday; 1 will work Sunday- Thursday; rotating holidays

Work Arrangement: Remote

Position Summary:

Performs concurrent reviews, including determining the member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists in evaluating inpatient services to validate the necessity and setting of care being delivered to the 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 medical 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

* Process denial management systems (claims, correspondence platform, appeals tracking)

* Prioritize Tasks: Review pending denial letters, escalations, and compliance deadlines

* Check Emails & Updates: Look for policy changes, payer updates, or internal communications that could affect denial handling