Clinical - Clinical Review Nurse - Concurrent Review

2 weeks ago


Woodland Hills, United States Axelon Full time

Location: Remote-needs to live in C
SHIFT: Monday through Friday 8am to 5pm (PST)

Duration:5+ month, This is a TEMP contract for a FTE on leave

Walk me through the day to day responsibilities of this the role and a description of the project:

  • Summary: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.
  • Job Responsibilities: Perform review of concurrent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director for secondary review. Complete medical necessity and level of care reviews for requested services using InterQual guidelines and refer to Medical Directors for review depending on case findings. Collaborate with various staff within provider networks and discharge planning team electronically and telephonically to coordinate member care. Conduct discharge planning. Educate providers on utilization and medical management processes. Provide clinical knowledge and act as a clinical resource to non-clinical team staff. Enter and maintain pertinent clinical information in various medical management systems.

Describe the performance expectations/metrics for this individual and their team:
  • Nurses are expected to Review an average of 20 cases/day

Job Description: 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.

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.

Pay Rate: $40 - 44/hr ***
Required Skills/Experience: Preferred Skills/ Experience: 1. Computer Skills- Microsoft, Teams, Zoom 1. Knowledge of InterQual reviews 2. Good communication skills for clinical rounds 2. 3. 2-4 years of hospital, managed care, UM exp
3. Education Requirement: Graduate from an accredited School of Nursing Education Preferred: ASN or BSN Software Skills Required: Microsoft, basic computer knowledge with electronic medical record programs Required Certifications: California Registered Nurse Required Testing: InterQual Interrater Reliability Testing

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