Concurrent Review RN (closed)
We are seeking a Concurrent Review RN to work in office for an expanding Managed Care organization. The position is an immediate need for a 3-4 month contract.
JOB SUMMARY: Performs technical and administrative work required to evaluate the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Licensed RN responsible for clinical review of all acute and sub-acute services for appropriateness based on medical criteria. This individual is responsible for the management of healthcare resources necessary and appropriate for achievement of desired acute and sub-acute outcomes and the coordination of alternative levels of care for membership.
- Performs on-site and/or telephonic review of acute and sub-acute services.
- Predicts and plans for patient’s needs from pre-admission, through acute and sub-acute care and post-discharge, in collaboration with the member.
- Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.
- Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.
- Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.
- Strives to maintain quality care while effectively utilizing resources.
- Identifies and reports any quality or utilization issues to the Medical Director.
- Acts in conjunction with the clinical team related to discharge planning e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy, durable equipment and disposable supplies.
- Documents all activities in the appropriate system(s) on a timely basis.
- Participates in rounds with the Medical Director.
- Review Plan appeal items for concurrent and retrospective reviews as required and requested.
- Monitors and facilities appropriate utilization of resources utilizing clinical criteria.
- Tracks and reports trends of inappropriate utilization of resources to the Medical Director.
- Participates in a multi-disciplinary clinical team to achieve positive member outcomes.
- Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.
- Utilizes effective communication, conflict management and negotiation skills.
- Utilizes excellent customer service principles to assist internal and external customers.
- Participates in Quality Improvement Process.
- Maintains member confidentiality.
- Other duties as requested or assigned.