Clinical Review Nurse - Concurrent Review
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Concurrent Review Nurse – Remote (California Market | Health Net)
Position Details
Schedule Monday–Friday, 8:00 AM – 5:00 PM PST
Licensure: Active California RN license required
Ideal Experience: Minimum of 2 years in acute care and managed care, with utilization management experience
Position Purpose
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 evaluating acuity level, resource consumption, length of stay, and discharge planning of members.
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 necessary decisions 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.
Education / Experience
Requirements: Graduate from an accredited school of nursing or hold a Bachelor’s degree in Nursing; 2–4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and the ability to determine overall member health, treatment needs, and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred.
License / Certification
Health Net of California RN license required.
Pay Range: $26.50 - $47.59 per hour.
Benefits: Competitive pay, health insurance, 401(k) 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.
Centene 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 any other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.
Seniority level: Not applicable.
Employment type: Full-time.
Job function: Health Care Provider.
Industries: Hospitals and Health Care and Insurance.