Job Details

Concurrent Review Nurse Job

We are seeking a dedicated Concurrent Review Nurse to perform concurrent reviews, assess members' overall health, evaluate the medical necessity of care, and contribute to discharge planning according to established care policies and guidelines. This role involves evaluating inpatient services to ensure the necessity and setting of care being delivered to the member.

Responsibilities:

• Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
• Productivity: 17-20 reviews a day and quality expectations must be met
• Partners with interdepartmental teams on projects within utilization management as part of the clinical review team
• Partners and works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
• Assesses members and/or families for post discharge needs and provide education on discharge planning options based on diagnoses, prognoses, resources, and/or preferences
• Manages 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
• Manages and collaborates with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
• Provides education to providers on utilization processes to ensure high quality appropriate care to members
• Partners with leadership to identify opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
• Oversees concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
• Provides insight and guidance on concurrent reviews to determine overall health of member, review the type of care being delivered to member, and approving treatment needs including discharge planning
• Provides guidance and expert knowledge, as appropriate, to utilization management team to address issues and validate the necessity and setting of care being delivered to the member
• Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
• Oversees 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
• Provides subject matter expertise based on prior experience as well as training to other team members
• Manages reporting to identify trends and provides recommendations to various teams
• Performs other duties as assigned
• Complies with all policies and standards

Essential Skills:

• Graduate from an Accredited School of Nursing or a Bachelor's degree in Nursing.
• 2 - 4 years of related experience
• Clinical knowledge and ability to determine overall health of members, including treatment needs and appropriate level of care.
• Knowledge of Medicare and Medicaid regulations.
• Understanding of utilization management processes.

Additional Skills & Qualifications:

• Case management experience.
• Clinical review skills.
• For Health Net of California: Texas nursing license or compact nursing license required.

Work Environment:

This position is scheduled from Monday-Friday, 8am - 5pm PST. The role involves working within health management systems and collaborating with healthcare providers, Medical Affairs, and care management teams. The dress code is professional attire suitable for a clinical setting.

Job Type:

100% Remote!

Pay and Benefits:

The pay range for this position is $35.00 - $40.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

Application Deadline:

This position is anticipated to close on Sep 26, 2025.

About Actalent:

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email ...@actalentservices.com for other accommodation options.