Clinical - Clinical Review Nurse - Concurrent Review - J00933

Position Title: Clinical Review Nurse

Work Location: Remote- Nationally but must have Compact license if not in KY. Ok with all time zones but must work EST

Assignment Duration: 6 months possibility of extension

Work Schedule: Mon- Fri 8-5pm EST

Work Arrangement: Remote

Position Summary:

Performs concurrent reviews, including determining 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 evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

Background & Context: My team does concurrent reviews for KY Medicaid's inpatient medical stays. We have two employees going out on leave for 4-5 months at the end of this year and will need help while they are out. The team is small and tight knit. It is a busy market. There is potential for upcoming hiring needs depending on how the medical leaves play out.

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 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

* Performs other duties as assigned

* Complies with all policies and standards

Qualification & Experience:

* Required: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 - 4 years of related experience. * Preferred: BSN * Required: LPN * Preferred: RN * Years of experience required: 2-4 years of related experience. * Disqualifiers: no UM background- must be tech savvy * Additional qualities to look for: ICU, Med-surge, Acute Care experience preferred. * Top 3 must-have hard skills stack-ranked by importance 1 Extensive clinical background. 2 Technologically Savvy 3 Must be able to multi-task.