Clinical Review Nurse - Corpus Christi - BravoTECH

    BravoTECH
    BravoTECH Corpus Christi

    1 week ago

    Description
    Job Description

    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 Bachelors 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
    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 members 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

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