Clinical - Clinical Review Nurse - Concurrent Review - J00933

Mindlance

🇺🇸 United States
Remote
Manager or above
2 hours ago

LPN
RN License

2 hours ago

Not enough detail in this posting to match

Job Profile Summary
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.

Education/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.

Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.

License/Certification:
LPN - Licensed Practical Nurse - State Licensure required
For Health Net of California: RN license required

Responsibilities
Performs concurrent reviews of member 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

EEO:

“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”

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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. 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. Comply with all policies and standards. Education/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. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required RN - Registered Nurse - State Licensure and/or Compact State Licensure For State of Nevada required
Story Behind the Need
What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?	For a UM CCR team, our primary focus is delivering timely, accurate, and clinically appropriate authorization reviews while maintaining compliance, quality, and positive member outcomes. Based on our UM program requirements and CCR operational expectations, several key initiatives drive success. 14 per day on average, 2.12 per hour. Weighted productivity about 95% along with audit scores above 95%
Candidate Requirements
Education/Certification	Required: Accredited School of Nursing or Bachelor’s degree in Nursing	Preferred:
Licensure	Required: LPN/RN	Preferred:
Years of experience required: 2 – 4 years of related experience. 2+ years of acute care experience required/UM or managed care exp preferred Disqualifiers: Additional qualities to look for:
Top 3 must-have hard skills stack-ranked by importance	1	Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
2	Knowledge of Medicare and Medicaid regulations preferred.
3	Knowledge of utilization management processes preferred.
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations	Projected Manager Candidate Review Date:	1-2 days post shortlisting
Type of Interviews:	Teams, phone, etc.
Required Testing or Assessment (by Vendor):
Next Steps

Clinical - Clinical Review Nurse - Concurrent Review - J00933 · Mindlance

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