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, contribute to discharge planning, and collaborate with healthcare providers in a remote setting.

Key responsibilities

• Conduct concurrent reviews to determine members' overall health and appropriate level of care
• Collaborate with Medical Affairs and healthcare providers to validate care delivery and approve medical determinations
• Document 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, with a minimum of 2 years in acute care
• Current RN license required for California or Compact State Licensure for Nevada
• Knowledge of Medicare and Medicaid regulations preferred
• Familiarity with utilization management processes preferred