Utilization Review Nurse

Title - Clinical Review Nurse - Concurrent Review

Duration - 6 months

Location - Remote TX

• 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

• 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.

• Requires Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience. 2+ years of acute care experience required.

• The nurse will be reviewing clinical faxed in by facilities for medical necessity. We are a close-knit team with a positive work environment. We help each other out and no one is left behind with a lot of work. The nurse gains valuable regarding commercial insurance.

• 8am-5pm CST.
• Will be reviewing cases for medical necessity all day. Will work from home with multiple monitors and needs to be able to multitask.
• Once off training, they will need to work one Saturday every other month.

• Graduate from an Accredited School of Nursing or bachelor’s degree in nursing
• Preferred: 2 – 4 years of related experience- 4 years is preferred
• Required:
  
  Texas RN Preferred
• Years of experience required: UM experience preferred not required
• Disqualifiers:
  Less than 2 years of nursing experience, no LPNs