State Licensed Concurrent Review Nurse

Job Summary

A company is looking for a Concurrent Review Case Manager to ensure members receive appropriate care through clinical reviews and care coordination.

Key Responsibilities

• Conducts pre-service and concurrent reviews of inpatient and outpatient services for medical necessity
• Collaborates with case managers, physicians, and community resources to facilitate care transitions
• Documents and communicates denial processes and ensures compliance with regulatory standards

Required Qualifications

• Licensed Registered Nurse (RN) in the state of residence
• 3+ years of clinical nursing experience
• Working knowledge of contract terms related to utilization management
• Familiarity with HIPAA regulations and NCQA standards
• Firm computer skills, including proficiency in Microsoft Office