Clinical Review Nurse - Concurrent Review
Core
Performs concurrent reviews to determine member health, evaluate medical necessity, validate inpatient care settings, and contribute to discharge planning.
Role type
Clinical Review Nurse (Utilization Management)
Builds
Utilization management decisions and discharge plans for healthcare members
Domain
Healthcare / Utilization Management
Required skills
Clinical knowledge to determine overall health and treatment needs, Knowledge of Medicare and Medicaid regulations, Knowledge of utilization management processes, Ability to review acuity level and resource consumption, Experience with health management systems
Preferred skills
Active and unrestricted New York State Registered Nurse (RN) license, Bachelor's degree in Nursing (BSN), 2 to 4 years of related experience
Technologies
Health management systems
Responsibilities
Performs concurrent reviews of member for appropriate care and setting, Reviews quality and continuity of care by reviewing acuity level and length of stay, Collects and maintains concurrent review findings and discharge plans in health management systems, Works with Medical Affairs and Medical Directors to discuss member care, Works with healthcare providers to approve medical determinations or provide recommendations, Reviews member's transfer or discharge plans to ensure timely discharge, Provides feedback to leadership on opportunities to improve appropriate level of care