California Licensed Clinical Review Nurse

Job Summary

Performing concurrent reviews to evaluate member health and care delivery, the full-time California Licensed Clinical Review Nurse will work remotely, managing on-call weekend and holiday rotations while ensuring appropriate levels of care and discharge planning.

Key responsibilities

• Conducts concurrent reviews to assess member health and appropriateness of care settings
• Collaborates with Medical Affairs and healthcare providers to validate medical necessity and approve care determinations
• Documents review findings and discharge plans 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, including 2+ years of acute care experience
• Licensed Practical Nurse (LPN) State Licensure required; RN State Licensure preferred
• Knowledge of Medicare and Medicaid regulations preferred
• Familiarity with utilization management processes preferred