Concurrent Review Nurse
Position Summary:
The Concurrent Review Nurse is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements.
Key Responsibilities:
- Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care.
- Evaluate clinical documentation against evidence-based criteria (e.g., InterQual®, MCG) to determine medical necessity and appropriate level of care.
- Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning.
- Communicate utilization review decisions and recommendations to providers and payers.
- Document all reviews, decisions, and communications in accordance with regulatory and organizational standards.
- Identify cases requiring escalation or peer review and follow established procedures.
- Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA.
- Participate in quality improvement initiatives and departmental meetings
- Registered Nurse (RN) license, active and in good standing, required.
- Associate or Bachelor’s degree in nursing (BSN preferred).
- Minimum 2 years of clinical experience (e.g., med-surg, critical care).
- At least 1 year of utilization review, case management, or managed care experience preferred.
- Knowledge of InterQual®, MCG, or other clinical review guidelines.
- Familiarity with Medicare/Medicaid and commercial insurance regulations.
- Strong analytical and clinical judgment skills.
- Effective communication and negotiation skills.
- Proficient with electronic medical records (EMRs) and utilization review platforms.
- Detail-oriented with excellent organizational skills.
- Remote