Clinical Review Nurse - Concurrent Review

Position Title: Clinical Review Nurse - Concurrent Review

Work Location: Remote - can reside anywhere within US as long as they have a compact license

Assignment Duration: 6 months

Work Schedule: 12-9 CST, Sunday-Thursday rotating holidays

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.

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:

* Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience

* Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred

* Knowledge of Medicare and Medicaid regulations preferred

* Knowledge of utilization management processes preferred

* License/Certification: LPN - Licensed Practical Nurse - State Licensure required

Additional Information: Generates, processes and maintains provider and member correspondence for preservice and concurrent review. Process denial management systems (claims, correspondence platform, appeals tracking). Prioritize Tasks: Review pending denial letters, escalations, and compliance deadlines. Check Emails & Updates: Look for policy changes, payer updates, or internal communications that could affect denial handling. Once fully trained, at least 2.6 denial letters per hour starting point is 5 - 10 letters per week when ramping before. Clinical review nurse manages time and productivity without in-office oversight and combines technical expertise, compliance knowledge, and strong communication skills in a virtual setting.