Clinical - Clinical Review Nurse - Concurrent Review - J00933

Job Description :

Job Title : Clinical Review Nurse - Concurrent Review

Duration : 6 months (Possible Extensions)

Location : Remote

Shift Schedule : Sunday Thursday | 12 : 00 PM 9 : 00 PM CST (Rotating Holidays)

Job Description

Position Purpose

The Clinical Review Nurse Concurrent Review is responsible for conducting concurrent utilization reviews to assess medical necessity, appropriateness of care, and level of service for inpatient members. This role supports discharge planning, ensures compliance with clinical guidelines, and collaborates with providers, medical directors, and care management teams. The position is fully remote and requires strong clinical judgment, productivity, and independent time management.

Key Responsibilities

Perform concurrent reviews to evaluate member health status, treatment plans, and appropriate level of care

Assess medical necessity using established utilization management policies, clinical guidelines, and regulatory requirements

Review acuity, length of stay, resource utilization, and discharge planning to ensure quality and continuity of care

Collaborate with Medical Directors and Medical Affairs on complex cases or care determinations

Communicate with healthcare providers to approve determinations or provide recommendations based on clinical findings

Document all review activities, findings, and actions accurately in utilization management systems

Assist with denial management processes, including correspondence, escalations, and compliance deadlines

Provide education to providers regarding utilization management processes and medical necessity criteria

Identify trends and provide feedback to leadership on opportunities to improve care quality and utilization outcomes

Collaborate with care management teams to ensure appropriate referrals and timely transitions of care

Meet productivity and quality benchmarks, including denial letter turnaround and review volumes

Maintain compliance with all policies, regulatory standards, and documentation requirements

Education & Experience

Graduate of an accredited School of Nursing or Bachelor's degree in Nursing

1 2 years of clinical nursing experience required

Prior experience in Utilization Management, Concurrent Review, or Denials Management strongly preferred

Knowledge of Medicare and Medicaid regulations preferred

Strong medical terminology and clinical documentation skills

License & Certification

Required : Active Compact Nurse Licensure (Multistate License)

Required : LPN or RN license (RN preferred)

Must be eligible to support Louisiana (LA)

Required Skills & Competencies

Strong multitasking and time management skills in a remote environment

Ability to adapt quickly to changing workflows and policies

High attention to detail and documentation accuracy

Comfortable working independently without in-office oversight

Proficiency with clinical systems, denial platforms, and correspondence tools

Additional Details

Fully remote, non-member-facing role

Typing and basic computer skills assessment required (90% pass rate)