Clinical Review Nurse - Concurrent Review
Core
Performs concurrent reviews of inpatient admissions and elective procedures to determine medical necessity, evaluate overall health, and contribute to discharge planning for Magnolia Health Plan members.
Role type
Clinical Review Nurse (Utilization Management)
Builds
Utilization management decisions and discharge plans for health plan members
Domain
Healthcare / Utilization Management
Required skills
Acute care nursing experience, Medical necessity evaluation, Discharge planning, Care setting validation, Health management systems documentation, Provider collaboration
Preferred skills
Medicare/Medicaid regulations knowledge, Utilization management process knowledge, Clinical knowledge for treatment needs determination
Technologies
Health management systems
Responsibilities
Review inpatient admissions and elective procedures for medical necessity; Evaluate member acuity level, resource consumption, and length of stay; Collaborate with Medical Directors on member care; Document concurrent review findings and discharge plans; Provide education to providers on utilization processes; Review transfer or discharge plans for timely transitions.
Seniority
Mid-level, hands-on IC