Clinical Review Nurse - Concurrent Review

Position Title: Clinical Review Nurse - Concurrent Review

Work Location: Remote - Prefer candidates in Central, Mountain or Pacific time zones

Assignment Duration: 6 months (Contract to Hire)

Work Schedule: (8 hour-day) Mon - Fri: business hours to cover 4 US time zones. Start times from 8am ET. End time to 5pm PT. Weekends/Holidays: Scheduled rotation.

Work Arrangement: Remote

Position Summary:

Analyzes authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Background & Context:

Strengthening the team's capacity to support the UM center of excellence and advance QAI objectives. The team will provide dedicated resources to enhance post-acute oversight, improve consistency, and support increased coordination across the continuum of care. Teams are collaborative, communicative and aligned around shared goals.

Key Responsibilities:

• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
• Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
• Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member
• Escalates authorization requests to Medical Directors as appropriate to determine appropriateness of care
• Assists with service authorization requests for a member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Collects, documents, and maintains all member's clinical information in health management systems to ensure compliance with regulatory guidelines
• Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members
• Provides feedback on opportunities to improve the authorization review process for members
• Performs other duties as assigned
• Complies with all policies and standards

Additional day-to-day detail from intake:

• Workload review for census management: Review assigned cases, prioritize new requests, cases due for continued-stay review, time-sensitive discharges, and cases approaching regulatory or internal turnaround-time requirements. Identify high-risk or complex members requiring early escalation.
• Clinical Review: Accessing medical management platforms for UM clinical medical necessity reviews for inpatient; Review the member's current clinical status, level of care, functional needs, treatment plan, progress, and discharge barriers. Apply the appropriate clinical criteria and benefit requirements to determine whether the requested level of care remains medically appropriate.
• Authorization documentation: Complete authorization activities within required timeframes and document the clinical rationale, criteria applied, communications, decisions, and next review date clearly and accurately in the medical management system.
• Level 2 escalation: Identify cases that do not clearly meet criteria, have significant clinical complexity, or require additional medical judgment. Prepare the case for medical director review and communicate relevant clinical information according to templated formats.
• Post-acute coordination: Evaluate appropriateness for lower level of care such as SNF, inpatient rehabilitation, LTACH, home health, or other post-acute care. Work with facilities, providers, case management, and other internal partners to obtain missing clinical information and support timely transitions of care.
• Interdisciplinary Collaboration: Participate in rounds, huddles, or case discussions to address complex cases, avoidable delays, barriers to discharge, readmission risk, and opportunities to transition members to the most appropriate setting. Reassess active cases as new clinical information becomes available. Monitor progress toward discharge goals and identify members who may be remaining at a higher level of care longer than clinically necessary.
• Quality and QAI support: Recognize patterns such as prolonged stays, repeat admissions, authorization delays, inconsistent provider practices, or gaps in transitions of care. Escalate trends that may represent opportunities for quality or process improvement.
• End of day reconciliation: Ensure reviews due that day are completed, outstanding clinical information is followed up on, urgent cases are handed off appropriately, and documentation accurately reflects the current status and next steps.

Qualification & Experience: