Clinical Review Nurse – Concurrent Review

Job Description:

• Perform concurrent reviews of inpatient medical admissions for pediatric and adult members within the LA Medicaid line of business
• Determine members’ overall health, appropriate care, medical necessity, and level of care
• Review acuity level, resource consumption, length of stay, and discharge planning
• Work with Medical Affairs and/or Medical Directors regarding member care
• Collect, document, and maintain concurrent review findings, discharge plans, and actions in health management systems
• Work with healthcare providers to approve medical determinations or provide recommendations
• Educate providers on utilization processes
• Provide leadership feedback on opportunities to improve level of care and medical necessity
• Review transfer and discharge plans to support timely transitions between levels of care and facilities
• Collaborate with care management on member referrals
• Comply with policies and standards and perform other assigned duties

Requirements:

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
• 2–4 years of related experience
• 2+ years of acute care experience required
• LPN state licensure required, or RN state licensure and/or Compact State
• 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
• Standard hours of 8am–5pm CST with weekend and holiday rotation
• Ability to conduct clinical reviews of inpatient medical admissions for pediatric and adult members
• Knowledge of utilization management policies and guidelines

Benefits:

• Health insurance
• 401K
• Stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible approach to work with remote, hybrid, field or office work schedules
• Additional forms of incentives may be included in total compensation