Clinical Clinical Review Nurse Concurrent Review J00933

Job Title: Clinical - Clinical Review Nurse - Concurrent Review

Location: Illinois (Multiple Locations)

Position Purpose

• The Utilization Review Nurse is responsible for conducting concurrent reviews to evaluate members overall health status the type and level of care being delivered medical necessity and discharge planning. The role ensures that inpatient services are appropriate clinically necessary and aligned with established care policies and guidelines.

Education & Experience Requirements

• Looking for a graduate from an accredited School of Nursing or Bachelors Degree in Nursing.
• 2 4 years of related experience required.
• Minimum 2 years of acute care experience is mandatory.
• Strong clinical knowledge with the ability to assess overall member health treatment needs and determine appropriate level of care preferred.
• Knowledge of Medicare and Medicaid regulations is preferred.
• Experience with utilization management processes preferred.

Licensure/Certification

• LPN (Licensed Practical Nurse) Active State Licensure required.
• RN preferred depending on state requirements.

Key Responsibilities

• Perform concurrent reviews to evaluate member health treatment appropriateness and care setting.
• Review quality and continuity of care including acuity level resource utilization length of stay and discharge readiness.
• Collaborate with Medical Directors/Clinical Leadership to review complex member cases.
• Document all review findings discharge plans and actions taken in internal health management systems per utilization management guidelines.
• Work closely with healthcare providers to approve or recommend services based on clinical criteria.
• Provide education to providers regarding utilization review processes to ensure appropriate and high-quality care.
• Identify opportunities for improvement in care levels medical necessities and clinical processes and communicate them to leadership.
• Review and support member transfers and discharges to ensure timely and appropriate transitions between levels of care.
• Collaborate with care management teams to refer members as needed.
• Perform additional duties as assigned.
• Ensure compliance with all organizational policies procedures and standards.