Clinical Review Nurse - Concurrent Review

Position Title: Clinical Review Nurse-Concurrent Review

Work Location: Remote (West Coast sourcing only)

Assignment Duration: 02+ Months

Work Schedule:

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  Training 8AM-5PM CST Mon-Fri (2 weeks, NO TIME OFF)

  
  
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  10-7 CST Monday-Friday

  
  
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  Holiday's as needed with notice
  
  Work Arrangement: Remote to West Coast (national sourcing but only West Coast)
  
  Position Summary:

  
  
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  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. Specific to the denial letters. No member or provider outreach
  
  Background & Context:

  
  
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  TLAR Reduction
  
  Key Responsibilities:

  
  
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  Denial Letters for Concurrent Review

  
  
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  Daily Points are the measurement

  
  
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  Will work within TruCare Classic, excel, outlook, word, one note.
  
  Qualification & Experience:

  
  
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  Education/Certification Required: RN - Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and Preferred:

  
  
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  Licensure Required: TX or compact license Preferred:

  
  
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  Years of experience required: 2 - 4 years of related experience. 2+ years of acute care experience required.

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

  
  
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  Knowledge of Medicare and Medicaid regulations preferred.

  
  
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  Knowledge of utilization management processes preferred.

  
  
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  Disqualifiers: LPN, most recent position must be related field

  
  
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  Additional qualities to look for: Self-starter

  
  
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  Top 3 must-have hard skills stack-ranked by importance
  
  1 Self-Starter/independent worker
  
  2 Time Management/attention to detail/accuracy
  
  3 Flexibility - willing to jump around with volume shifts in specific areas