Clinical Review Nurse - Concurrent Review

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.

nKey Details: This is a remote position. The required schedule is Monday- Friday 8:00 am-5:00 pm Pacific Standard Time (PST) and also includes a regular weekend and holiday rotation. Must hold an active RN license in California.

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

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

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

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nnCollects, documents, 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

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

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nnAssists with providing education to providers on utilization processes to ensure high quality appropriate care to members

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nnProvides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines

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

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nnCollaborates with care management on referral of members as appropriate

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nnPerforms other duties as assigned.

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nnComplies with all policies and standards.

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n nEducation/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required.

nClinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.

nKnowledge of Medicare and Medicaid regulations preferred.

nKnowledge of utilization management processes preferred.

nLicense/Certification:

nnFor Health Net of California: RN license required

n nPay Range: $27.02 - $48.55 per hour

nAt Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

nCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

nCentene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

nQualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Worksite address

sacramento, CA, 95828, US

Who can apply

Review the original listing for work authorization, qualifications and employer requirements.