California Licensed Clinical Review Nurse

Job Summary

Performing concurrent reviews to assess member health and care appropriateness, the full-time California Licensed Clinical Review Nurse will evaluate medical necessity, collaborate with healthcare providers, and contribute to discharge planning in a remote setting.

Key responsibilities

• Conduct concurrent reviews to determine overall health and appropriate level of care for members
• Collaborate with Medical Affairs and healthcare providers to discuss care delivery and approve medical determinations
• Document findings and maintain member records in compliance with 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 a minimum of 2 years in acute care
• Knowledge of Medicare and Medicaid regulations preferred
• Understanding of utilization management processes preferred
• Current state licensure as a Licensed Practical Nurse (LPN) required