Concurrent Review RN

Are you a clinically strong RN who thrives in a dynamic healthcare environment and enjoys collaborating across the continuum of care P3 Health Partners is seeking a Concurrent Review RN to play a critical role in ensuring patients receive the right care at the right time and in the most appropriate setting.

In this role youll work closely with hospitals physicians specialists care teams and health plan partners to support appropriate utilization of healthcare resources facilitate smooth care transitions and improve patient outcomes. Your expertise will directly contribute to P3s commitment to the Quadruple Aim: improving health outcomes enhancing the patient and provider experience and reducing the cost of care.

As a Concurrent Review RN youll leverage your clinical expertise and utilization management knowledge to evaluate medical necessity coordinate care transitions and collaborate with healthcare teams to ensure optimal patient care.

• Promote the mission vision and values of P3 Health Partners.
• Perform telephonic and onsite utilization reviews including prior authorization concurrent review and transition of care evaluations.
• Review and approve services within scope of authority and escalate cases requiring additional review when appropriate.
• Apply evidence-based review criteria including:
  • Health plan benefits
  • CMS guidelines
  • Local and National Coverage Determinations (LCD/NCD)
  • InterQual and MCG criteria
• Utilize clinical judgment to assess medical necessity level of care and appropriate service utilization.
• Collaborate with hospitals providers and internal stakeholders to support discharge planning and care transitions.
• Request and review additional clinical documentation to support utilization review decisions.
• Escalate complex cases and medical necessity questions to the Medical Director as needed.
• Coordinate care with physicians specialists emergency department personnel patients and families.
• Partner with provider network teams and Medical Management departments to align care plans and support positive patient outcomes.
• Educate providers and clinical staff regarding utilization management processes criteria and requirements.
• Serve as a clinical resource and subject matter expert for non-clinical team members.
• Identify opportunities to close care gaps and improve patient outcomes.
• Accurately document all clinical reviews communications and decisions within designated systems.

You are a highly skilled clinician with a strong understanding of utilization management care coordination and evidence-based decision making. You are comfortable working independently while building strong relationships across healthcare settings.

• Strong clinical knowledge of acute post-acute and transitional care management.
• In-depth understanding of utilization management principles and medical necessity review processes.
• Experience applying evidence-based criteria including InterQual MCG and CMS guidelines.
• Excellent communication skills with the ability to interact effectively with physicians hospital personnel patients and families.
• Strong critical thinking assessment and problem-solving abilities.
• Ability to navigate complex or sensitive discussions regarding level of care and service authorization decisions.
• Exceptional organizational skills with the ability to manage multiple priorities and deadlines.
• Proficiency with Microsoft Office applications and medical management software platforms.
• Ability to work independently while collaborating effectively within interdisciplinary teams.
• Adaptability and commitment to continuous learning in an evolving healthcare environment.

• Graduate of an accredited School of Nursing.
• Active Registered Nurse (RN) license in Oregon with the ability to obtain and maintain licensure in multiple states.
• Minimum of four (4) years of clinical nursing experience.
• Minimum of two (2) years of experience in a managed care Medicare Advantage or HMO environment.
• Experience conducting medical necessity reviews and applying evidence-based clinical guidelines.

• Bachelor of Science in Nursing (BSN).
• Previous Emergency Department (ED) experience.
• Previous Intensive Care Unit (ICU) experience.
• Experience in Case Management and/or Utilization Management.
• Experience working with InterQual MCG CMS guidelines and transitions of care programs.

• Monday - Friday 8 AM - 5 PM PST

• This role offers a hybrid work arrangement. Candidates will follow our hybrid schedule working in office three days per week.

Salary Range: $90000 - $100000 annually

People. Passion. Purpose.

At P3 Health Partners our promise is to guide our communities to better health unburden clinicians align incentives and engage patients. We are a physician-led organization relentless in our mission to overcome obstacles and positively disrupt the business of healthcare transforming it from sickness care into wellness guidance.

As a Concurrent Review RN youll play an essential role in helping patients navigate the healthcare system while ensuring high-quality evidence-based care. Your expertise will help improve outcomes support providers and ensure patients receive the appropriate care at every stage of their healthcare journey.

At P3 youll collaborate with passionate healthcare professionals who are committed to innovation teamwork and delivering meaningful results. If you are passionate about your work eager to have fun and motivated to be part of a fast-growing organization where your contributions truly make a difference wed love to hear from you.

Join us in transforming healthcare and helping communities achieve better health outcomes.