Clinical Review Nurse - Concurrent Review

Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities

Productivity 17-20 reviews a day and quality expectations must be met

Partners with interdepartmental teams on projects within utilization management as part of the clinical review team

Partners and works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered

Assesses members and/or families for post discharge needs and provide education on discharge planning options based on diagnoses, prognoses, resources, and/or preferences

Manages 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

Manages and collaborates with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings

Provides education to providers on utilization processes to ensure high quality appropriate care to members

Partners with leadership to identify opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines

Oversees concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care

Provides insight and guidance on concurrent reviews to determine overall health of member, review the type of care being delivered to member, and approving treatment needs including discharge planning

Provides guidance and expert knowledge, as appropriate, to utilization management team to address issues and validate the necessity and setting of care being delivered to the member

Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member

Oversees 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

Provides subject matter expertise based on prior experience as well as training to other team members

Manages reporting to identify trends and provides recommendations to various teams

Performs other duties as assigned

Complies with all policies and standards