Clinical - Clinical Review Nurse - Concurrent Review - J00933

Job Profile Summary
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.

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
For Health Net of California: RN license required

Responsibilities
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

EEO:

“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”

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Job Profile Summary Position Purpose: Analyzes authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. Education/Experience: Required: 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 For Health Net of California: RN license required Responsibilities Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards
Story Behind the Need
What is the purpose of this team? Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?		Strengthening the team’s capacity to support the UM center of excellence and advance our QAI objectives. The team will provide dedicated resources to enhance post-acute oversight, improve consistency, and support increased coordination across the continuum of care. Teams are collaborative, communicative and aligned around shared goals. Roles and expectations are clear while still allowing flexibility to support one another and adapt to changing priorities.
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?		Day to day Responsibilities Workload review for census management : Review assigned cases, prioritize new requests, cases due for continued-stay review, time-sensitive discharges, and cases approaching regulatory or internal turnaround-time requirements. Identify high-risk or complex members requiring early escalation. Clinical Review : Accessing medical management platforms for UM clinical medical necessity reviews for inpatient; Review the member’s current clinical status, level of care, functional needs, treatment plan, progress, and discharge barriers. Apply the appropriate clinical criteria and benefit requirements to determine whether the requested level of care remains medically appropriate. Authorization documentation : Complete authorization activities within required timeframes and document the clinical rationale, criteria applied, communications, decisions, and next review date clearly and accurately in the medical management system. Level 2 escalation : Identify cases that do not clearly meet criteria, have significant clinical complexity, or require additional medical judgment. Prepare the case for medical director review and communicate relevant clinical information according to templated formats. Post-acute coordination : Evaluate appropriateness for lower level of care such as SNF, inpatient rehabilitation, LTACH, home health, or other post-acute care. Work with facilities, providers, case management, and other internal partners to obtain missing clinical information and support timely transitions of care. Interdisciplinary Collaboration : Participate in rounds, huddles, or case discussions to address complex cases, avoidable delays, barriers to discharge, readmission risk, and opportunities to transition members to the most appropriate setting. Reassess active cases as new clinical information becomes available. Monitor progress toward discharge goals and identify members who may be remaining at a higher level of care longer than clinically necessary. Quality and QAI support : Recognize patterns such as prolonged stays, repeat admissions, authorization delays, inconsistent provider practices, or gaps in transitions of care. Escalate trends that may represent opportunities for quality or process improvement. End of day reconciliation : Ensure reviews due that day are completed, outstanding clinical information is followed up on, urgent cases are handed off appropriately, and documentation accurately reflects the current status and next steps. Metrics: target performance 2 reviews/hour TC; 2.4 reviews per hour CC. maintaining TAT timeframes, RN to MD referral and alignment rates. The opportunity to be part of a team that is being built and shaped for the future; growing their expertise while helping implement a refined care model designed to best support our members across the continuum of care.
Candidate Requirements
Education/Certification	Required: Graduate from an accredited school of nursing or bachelor’s degree in nursing and 2 – 4 years of related experience			Preferred: Compact licensure will work OR willing to acquire a required state license
Licensure	Required: RN - State Licensure			Preferred: Experience with Medical necessity tools such as InterQual or MCG
Years of experience required: 2+ years of acute care experience required 2 – 4 years of related experience Disqualifiers: No license. No direct care experience in an acute inpatient setting. Additional qualities to look for:
Top 3 must-have hard skills stack-ranked by importance		1	Strong Clinical Judgment and Critical Thinking Requires analyzing complex clinical situations and applying UM criteria and guidelines Agile, ability to manage competing priorities
		2	Communication & Care Coordination • Clear, concise communication with providers, care teams, and insurance representatives • Ability to advocate for appropriate care while maintaining positive provider relationships • Skilled at documenting clinical findings and review decisions accurately and timely
		3	Knowledge of Regulations, Policies, and Payer Requirements • Familiarity with CMS guidelines, payer policies, authorization processes, and compliance standards • Ability to apply regulatory knowledge when making review decisions • Ensures consistent adherence to organizational and industry guidelines
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations		Projected Manager Candidate Review Date:			1-2 days post shortlisting
		Type of Interviews:			Camera on video (Teams)
		Required Testing or Assessment (by Vendor):			N/A
Next Steps
Do you have any upcoming PTO?
Colleagues to cc/delegate		Interviews: will add delegates CC/ Maria Boatright : Bridget Wyss, Elizabeth Ulmer, Nicholette Boullion and Audrey Lee TC/ Shani Bell : Rachel L Rodriguez, Tamia Smalls
Compliance Questions
(Department of Defense) Will this role operate, support, or utilize DOD data, systems, and/or infrastructure, requiring a National Agency Check with Law and Credit Checks (NACLC)? (Vendors: If yes, NACLC check is required).		N/A