Clinical Clinical Review Nurse Concurrent Review J00933
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Job Location:
McAllen, TX - USA
Monthly Salary:
Not Disclosed
Posted on:
10 hours ago
Vacancies:
1 Vacancy
Job Summary
Job Description:
Job Title: Clinical Review Nurse -Concurrent Review
Duration: 6 months (Contract To Hire)
Location: Remote - TX
Shift Schedule: Tuesday Saturday 8:00 AM 5:00 PM CST (Firm schedule)
Position Overview
The Clinical Review Nurse Concurrent Review is responsible for performing concurrent reviews of inpatient services to assess medical necessity appropriateness of care and level of care in accordance with Centene state and federal guidelines. This role plays a critical part in ensuring quality cost-effective care while supporting timely discharge planning and continuity of care.
This is a fast-paced production-oriented role requiring strong clinical judgment multitasking ability and comfort working independently in a remote environment.
Key Responsibilities
- Perform concurrent reviews to determine the appropriateness medical necessity and level of care for inpatient admissions.
- Evaluate member health status acuity length of stay resource utilization and discharge planning needs.
- Review clinical documentation submitted by facilities to support medical necessity determinations.
- Collaborate with Medical Directors and Medical Affairs to discuss complex cases and care delivery.
- Communicate with healthcare providers to approve determinations or provide recommendations based on clinical findings.
- Document all review activities findings and actions in health management systems in compliance with utilization management policies.
- Support timely and appropriate member transitions across levels of care.
- Provide education to providers on utilization review processes and guidelines.
- Partner with care management teams for referrals and coordination as appropriate.
- Identify and communicate opportunities for improvement related to quality medical necessity and utilization practices.
- Maintain compliance with all regulatory accreditation and organizational standards.
- Perform additional duties as assigned.
Typical Day in the Role
- Work from a task-based queue reviewing inpatient cases throughout the day.
- Review clinical documentation for medical necessity and appropriateness of care.
- Collaborate closely with team leads and peers to meet daily productivity and quality targets.
- Utilize multiple systems and monitors while managing a high-volume workload.
- Participate in team collaboration and support within a close-knit fast-paced environment.
- Once fully trained work one Saturday every other month as part of rotation.
Required Qualifications
Education
- Graduate from an Accredited School of Nursing or Bachelors Degree in Nursing
Licensure
- Active Texas RN license (Required)
- LPNs are not eligible for this role
Experience
- Minimum 2 years of nursing experience
- 2 years of acute care experience required
- Utilization Management or Concurrent Review experience preferred but not required
- Knowledge of Medicare and Medicaid regulations preferred
Key Skills & Competencies
- Strong clinical judgment and critical thinking
- Ability to multitask in a high-volume deadline-driven environment
- Fast learner with strong adaptability
- Computer savvy with comfort navigating multiple systems
- Excellent documentation and organizational skills
- Strong collaboration and communication skills
- Ability to work independently in a remote setting
Additional Role Details
- Fully remote role (Texas-based candidates only)
- No member-facing or field-based responsibilities
- No driving required
- Teams interview (camera on)
- Contract-to-hire opportunity with potential for extension or conversion
Key Skills
- CSS
- Cloud Computing
- Health Education
- Actuary
- Building Electrician
