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.


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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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. 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
Story Behind the Need
What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) 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?		The Utilization Management team review members who are currently receiving inpatient services to ensure that care remains medically necessary, appropriate, and provided at the correct level of care. The review nurse assesses the member’s clinical status, perform continued stay reviews, facilitate discharge planning and promote timely, appropriate care. The need is driven by needing to backfill FTE positions. There are no upcoming hiring needs and this is not a part of a larger hiring initiative.
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?			The concurrent review nurse spends the day performing medical necessity reviews of inpatient admissions and continued stays apply clinical criteria and guidelines such as InterQual, internal clinical policies and plan specific requirements. The nurse also communicates with hospitals, review clinical documentation, making authorization determinations within nursing scope, identifying discharge planning needs and barriers, collaborate with case management and other staff as well as other duties. The CCR nurse is required to process 2.2 reviews per hour (14-16 reviews daily). Concurrent Review Nurses perform a highly specialized function that combines medical necessity review, inpatient utilization management, discharge planning, transition-of-care coordination, and provider collaboration. The role requires continuous clinical assessment throughout a member's hospitalization, proactive identification of discharge barriers, coordination of post-acute services, and close collaboration with providers, Medical Directors, and Care Management teams to ensure appropriate utilization, regulatory compliance, safe transitions of care, reduced length of stay, and prevention of avoidable readmissions.
Candidate Requirements
Education/Certification	Required: Associate degree				Preferred: Bachelor
Licensure	Required: Registered Nurse License (MS or Compact)				Preferred: RN License
Years of experience required: 2 years Disqualifiers: LPN Additional qualities to look for: Flexible, Results oriented
Top 3 must-have hard skills stack-ranked by importance			1	Basic Computer Knowledge
			2	Critical Thinking Skills
			3	Time Management/Organized
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:			Teams, phone, etc.
			Required Testing or Assessment (by Vendor):			n/a
Next Steps
Do you have any upcoming PTO?			None
Colleagues to cc/delegate			Angela Brown, Senior Manager