Responsibilities

• Perform concurrent reviews of members to assess their overall health status and determine the appropriateness of care being delivered.
• Evaluate medical necessity for inpatient services and ensure compliance with established care policies and guidelines.
• Collaborate with Medical Affairs and Medical Directors to discuss and optimize member care.
• Review quality and continuity of care by analyzing acuity levels, resource consumption, length of stay, and discharge planning.
• Document and maintain comprehensive records of concurrent review findings, discharge plans, and actions taken regarding member care.
• Contribute to discharge planning efforts to ensure a smooth transition for members.
• Participate in on-call weekend and holiday rotations as required.

Requirements

• Registered Nurse (RN) license is required.
• Minimum of 3 years of clinical nursing experience, preferably in a healthcare management or utilization review setting.
• Strong understanding of medical necessity criteria and care management principles.
• Excellent communication and interpersonal skills to effectively collaborate with medical staff and members.
• Ability to work independently and make sound clinical decisions in a remote setting.
• Proficient in medical documentation and electronic health record systems.
• A commitment to patient-centered care and the ability to advocate for members' needs.

Benefits

• Competitive salary and comprehensive benefits package including health, dental, and vision insurance.
• Flexible work arrangements that support work-life balance, including remote work options.
• Opportunities for professional development and continuing education.
• Supportive team environment with resources to foster your success.
• Generous paid time off and holiday schedule.
• Employee wellness programs to promote health and well-being.