Clinical Review Nurse - Concurrent Review NICU

Position Purpose: 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.

Key Details: There are 3 positions available; remote/work from home. The work schedule is Monday - Friday 8am - 5pm based on the time zone in which you reside (prefer applicants reside in either central or eastern time zones). These positions require: Minimum 3 years of level III or IV NICU experience. NICU certification is helpful. Compact RN licensure is preferred with the ability to achieve licensures in non-compact states (cost reimbursed by the company). Role will support both Medicaid and Ambetter/market place insurance members.

• 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.

Education/Experience: 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. 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.

License/Certification

• LPN - Licensed Practical Nurse - State Licensure required
• RN - Registered Nurse - State Licensure and/or Compact State Licensure For State of Nevada required