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HCS Job Title: Concurrent Review RN 
Company Job Title: Clinical Review Nurse - Concurrent Review 
 
 
Working with Hiring Manager Shelly McDonald-Mercer and Staffing Specialist Melissa Carter 
 
Req: 173792-1 
 
No Griffin 
 
Workday Job Code:  J00933 
 
Vaccination NOT REQUIRED 
# of Openings:  1 pos, 2 sub spots 
 
If Contract, Length of Assignment:  6 months, potential to extend/convert 
MU or BR:  63 
Compensation Notes:  $38 to $42 an hour 
Location:  Remote in Texas, CST 
Shift: Tues - Sat 8am-5pm (Training will be M-F 8AM – 5PM) 
Start Date: ASAP 
Interview Times/Interviewer: Virtual with Shelly 
Minimum Education/Licensures/Qualifications: 
Must include city and state on resume
<ul>
	<li style="margin-top: 0.0in;margin-right: 0.0in;margin-bottom: 0.0in;margin: 0.0in 0.0in 8.0pt;">Must have clear and active TX RN license 
	<li style="margin-top: 0.0in;margin-right: 0.0in;margin-bottom: 0.0in;margin: 0.0in 0.0in 8.0pt;">2+ years of  recent nursing experience in Concurrent review/utilization review from an MCO -  please specify on resume how many cases they were reviewing per day and if they were for inpatient and/or outpatient, Medicaid/Medicare and/or Commercial lines of business
	<li style="margin-top: 0.0in;margin-right: 0.0in;margin-bottom: 0.0in;margin: 0.0in 0.0in 8.0pt;">Experience using clinical criteria to determine medical necessity such as InterQual Criteria or Milliman Care Guidelines (MCG) – please specify on resume what criteria they have used
	<li style="margin: 0.0in 0.0in 8.0pt;">Graduate from accredited school of nursing OR Bachelor’s degree in nursing
</ul>
Preferred but not a must:

<ul>
	<li style="margin-top: 0.0in;margin-right: 0.0in;margin-bottom: 0.0in;margin: 0.0in 0.0in 8.0pt;">Experience working remotely – please specify on resume if any positions were remote
	<li style="margin: 0.0in 0.0in 8.0pt;">4+ years of related nursing experience 
</ul>
 
Types of Candidates to Submit to Sales Rep: 
Best Candidate: Concurrent Review RN with 2+ years from MCO setting   
Second Best Candidate: UM RN with 2+ years from another MCO setting 
Third Best Candidate: Prior Auth RN reviewing inpatient admissions with 2+ years from another MCO setting 
 
 
Day to Day Duties: 
Will have task queue to work from. Will work closely with team lead and team members to meet daily deadlines. Will be reviewing cases for medical necessity all day. Will work from home with multiple monitors and needs to be able to multitask. Once off training, they will need to work one Saturday every other month. 
Performs concurrent reviews of members for appropriate care and setting to determine overall health and appropriate level of care 
 
Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member 
 
Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered 
 
Collects, 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 
 
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings 
 
Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members 
 
Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines 
 
Reviews 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 
Performs other duties as assigned 
 
Complies with all policies and standards 
 
About the Team: 
This is a fast-paced role. The nurse will be reviewing clinical faxed in by facilities for medical necessity.  We are a close-knit team with a positive work environment. We help each other out and no one is left behind with a lot of work. The nurse gains valuable regarding commercial insurance 
 
What previous job titles or background work will in this role? 
Concurrent Review, Utilization Management experience. They need to have strong computer, documentation, and communication skills.

Utilization Management

$38 - $42/hr

About this job