Concurrent Review Nurse (163578)

Clinical Review Nurse – Concurrent Review (RN)

Remote | Texas Residents Only

Pay : $40–$43 / hr

Schedule : Tuesday–Saturday | 8 : 00 AM – 5 : 00 PM CST

Contract-to-Hire | 6-Month Contract with Potential to Convert

About the Role

We are seeking an experienced Clinical Review Nurse (Concurrent Review) to perform utilization review activities, assess medical necessity, and support discharge planning and appropriate care coordination. This role works closely with providers and internal medical leadership to ensure high-quality, cost-effective patient care compliant with guidelines and standards.

Key Responsibilities

• Perform concurrent reviews to determine member health status, treatment needs, and the medical necessity of services and level of care.
• Review quality and continuity of care through acuity level, resource utilization, length of stay, and discharge planning.
• Collaborate with Medical Directors and Medical Affairs to discuss and evaluate care plans.
• Document concurrent review findings, discharge plans, and actions within health management systems according to UM guidelines.
• Work with healthcare providers to support or recommend clinical determinations.
• Provide education to providers to ensure appropriate medical care and adherence to utilization standards.
• Review transfer and discharge plans for timely movement across levels of care.
• Collaborate with care management teams regarding referrals and follow-up needs.
• Maintain compliance with all policies, regulations, and quality standards.
• Perform other duties as assigned.

Required Qualifications

Preferred Qualifications

Skills & Competencies

Benefits of This Opportunity