Clinical Review Nurse - Concurrent Review
$56,202–$100,984 year
RemoteMissouri, United States
Job Summary
Conduct concurrent reviews for Medicaid members by determining overall health, evaluating medical necessity, and validating the appropriateness of care settings and discharge planning. Review acuity levels, resource consumption, and length of stay to ensure quality and continuity of care while collaborating with healthcare providers to approve medical determinations. Document findings and recommendations in health management systems, assist with provider education on utilization processes, and provide feedback to leadership on improving level of care. Work Monday through Friday from 8am to 5pm central time with 1-2 rotational holidays, fully remote from a Missouri residence.
Required Qualifications
- Reside in the state of Missouri
- Hold an active Missouri RN licensure
- Monday - Friday, 8am - 5pm central time zone with 1 - 2 rotational holidays/year
- Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
- 2 - 4 years of related experience
- 2+ years of acute care experience
- RN - Registered Nurse - State Licensure and/or Compact State Licensure for MO Medicaid
Desired Qualifications
- Strong clinical background
- Managed care experience
- Utilization management/review experience
- Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care
- Knowledge of Medicare and Medicaid regulations
- Knowledge of utilization management processes
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