California Licensed Clinical Review Nurse

Job Summary

To support the Medical Management/Health Services team, the full-time California Licensed Clinical Review Nurse will perform concurrent reviews to assess members' health, evaluate medical necessity, and contribute to discharge planning while working remotely and adhering to PST hours.

Key responsibilities

• Conduct concurrent reviews to determine the appropriateness of care and setting for members
• Collaborate with Medical Affairs and healthcare providers to validate medical determinations and improve care quality
• Document and maintain findings, discharge plans, and actions in health management systems according to utilization management policies

Required qualifications

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing
• 2 - 4 years of related experience, with at least 2 years in acute care
• Current RN license in California
• Knowledge of Medicare and Medicaid regulations preferred
• Familiarity with utilization management processes preferred