Concurrent Review RN

Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.

• Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations

• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings

• Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care

• Conduct discharge planning

• Educate providers on utilization and medical management processes

• Provide clinical knowledge and act as a clinical resource to non-clinical team staff

• Enter and maintain pertinent clinical information in various medical management systems

• Direct care to participating network providers

• Participate in utilization management committees and work on special projects related to utilization management as needed

Qualifications:

-RN, BSN preferred.

-2+ years of clinical nursing experience in an acute care setting

-1+ years of utilization management experience in a managed care setting. To start with this is a must!

-Knowledge of utilization management principles and healthcare managed care.

-Experience with medical decision support tools (i.e. Interqual, NCCN or Miliman) and government sponsored managed care programs * strongly preferred but not a must

Shift

8-5

Interested in being considered?

If you are interested in applying to this position, please contact Ashley Greene at 407-478-0332 ext 169

and click the Green I’m Interested Button to email your resume.