Clinical Review Nurse – Concurrent Review – J00933

Title: Clinical Review Nurse – Concurrent Review – J00933
Location: Remote
Job Summary
Performs concurrent reviews to assess members’ overall health, evaluate the care being delivered, determine medical necessity and appropriate level of care, and contribute to discharge planning in accordance with care policies and guidelines. Assists in evaluating inpatient services to validate the necessity and setting of care.

Key Responsibilities

• Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care.

• Review quality and continuity of care, including acuity level, resource consumption, length of stay, and discharge planning.

• Collaborate with Medical Affairs and Medical Directors to discuss member care as needed.

• Collect, document, and maintain concurrent review findings, discharge plans, and actions in health management systems according to utilization management policies and guidelines.

• Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.

• Educate providers on utilization management processes to support high-quality, appropriate care.

• Provide leadership with feedback on opportunities to improve level-of-care decisions and medical necessity determinations based on clinical policies and guidelines.

• Review transfer and discharge plans to support timely transitions between levels of care and facilities.

• Collaborate with Care Management to refer members as appropriate.

• Perform other duties as assigned and comply with all policies and standards.

Qualifications
Required

• 2–4 years of related experience.

• At least 2 years of acute care experience.

• Clinical knowledge and ability to assess members’ overall health, treatment needs, and appropriate level of care.

• Graduation from an accredited School of Nursing or a Bachelor’s degree in Nursing.

Required Certification & Licensure

• Licensed Practical Nurse (LPN) state licensure.

• For Health Net of California: Registered Nurse (RN) license required.

Working Conditions
Position may be based in a hospital or ambulatory/mobile imaging setting. Exposure to radiation, high-voltage equipment, and infectious diseases is possible with appropriate safety precautions. Position may require assisting with patient transfers and moving equipment.
Why work at OpTech? 
OpTech is a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work at OpTech, not only do you get health and dental benefits, but you also have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! 
By submitting your application, you acknowledge that recruiting technologies, including AI-assisted tools, may be used to support candidate evaluation, sourcing, matching, and communications. 
OpTech is an Equal Opportunity Employer (EOE), all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.