Clinical Review Nurse - Concurrent Review

Spectraforce Technologies
United States, Texas, Houston
Sep 09, 2025
Position Title: Clinical Review Nurse - Concurrent Review Work Location: Remote Texas CST Assignment Duration: 6 months Work Schedule: 10am-7pm CST, Schedule can be Sun-Thurs or Tues-Sat Position Summary: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Background & Context: * TX has doubled in enrollment this year so far. We are needing nurses who can cover late shift 10am-7 pm and weekends as that is our highest need right now. This will be for Texas Ambetter Superior Health Product. Our team is a team player centered culture and we try to have fun within our weekly huddles to keep morale up through the high caseload. Key Responsibilities: Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Qualification & Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: State Licensure required- TX - RN Candidate Requirements / Additional Details (verbatim bullets): Required: RN Must haves: 2-4 years of hospital experience, multi tasking, time management, quick learner, go with the flow attitude, computer savvy Nice to haves: UM, Clinical/managed care experience Disqualifiers: unable to multi task, disorganized, not willing to make calls, not computer savvy Performance indicators: Will be monitoring productivity daily Top 3 must-have hard skills: 1 TX RN license or compact state license; 2 Communication skills; 3 Documentation/Computer skills