[Hiring] Clinical Review Nurse @Pyramid Consulting

Role Description

Immediate need for a talented Clinical Review Nurse - Concurrent Review. This is a 06+ months contract opportunity with long-term potential and is located in U.S (Remote).

Key Responsibilities:

• Perform concurrent reviews of members to determine overall health and appropriate level of care.
• Review quality and continuity of care by assessing acuity levels, resource consumption, length of stay, and discharge planning.
• Collaborate with Medical Affairs and/or Medical Directors to discuss member care.
• Document and maintain concurrent review findings and discharge plans in health management systems.
• Work with healthcare providers to approve medical determinations based on concurrent review findings.
• Educate providers on utilization processes to ensure high-quality care.
• Provide feedback to leadership on opportunities to improve care levels and medical necessity.
• Review member transfer or discharge plans to facilitate timely discharges.
• Collaborate with care management for appropriate member referrals.
• Maintain productivity standards of an average of 14 reviews per day, with a weighted productivity target of 95% and audit scores above 95%.

Qualifications

• 2-4 years of related experience, with a minimum of 2 years in acute care required; experience in utilization management or managed care preferred.
• Required: Accredited School of Nursing or bachelor’s degree in nursing.
• Required: RN licensure.
• Clinical knowledge to determine overall health and treatment needs of members.
• Knowledge of Medicare and Medicaid regulations preferred.
• Familiarity with utilization management processes preferred.

Requirements

• Pay Range: $35.80 - $39.10/hour.
• Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Benefits

• Health insurance (medical, dental, vision).
• 401(k) plan.
• Paid sick leave (depending on work location).