Clinical Review Nurse - Concurrent Review
Core
Performs concurrent reviews to determine member overall health, evaluate medical necessity, and validate inpatient care settings and discharge plans.
Role type
Clinical Review Nurse (Concurrent Review)
Builds
Utilization management decisions for member care levels and discharge timing
Domain
Healthcare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Acute care nursing experience, Medical necessity evaluation, Care policy interpretation, Discharge planning, Health management system documentation, Provider collaboration
Preferred skills
RN licensure, Medicare/Medicaid regulations knowledge, Utilization management processes knowledge, Clinical knowledge of treatment needs
Technologies
Health management systems
Responsibilities
Perform concurrent reviews of member care and settings, Evaluate medical necessity and acuity levels, Collaborate with providers on medical determinations, Document review findings and discharge plans, Assist with provider education on utilization processes, Review transfer and discharge plans for timely transitions
Seniority
Mid-level, hands-on IC