Clinical Review Nurse - Concurrent Review

Position Title: Clinical Review Nurse-Concurrent Review

Work Location: Please only source in WEST COAST (Working hours listed in daily schedule)

Assignment Duration: 6 Months Possibility to extend or convert

Work Schedule:

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

  
  
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  12-9 CST Tuesday-Saturday

  
  
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  Holiday's as needed with notice

  
  

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.

Background & Context:

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  TLAR Reduction

  
  

Key Responsibilities:

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  Specific to the denial letters. No member or provider outreach

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

  
  
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  Required: TX or compact license

  
  
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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

     
     
     
     
     
     
     

     Candidate Requirements
     Education/Certification	Required: RN - Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and	Preferred:
     Licensure	Required: TX or compact license	Preferred:
     Years of experience required: 2 - 4 years of related experience. 2+ years of acute care experience required. 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. Disqualifiers: LPN, most recent position must be related field Additional qualities to look for: Self-starter
     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