Concurrent Review Nurse
UniVida Medical Centers
Concurrent Review Nurse: Description
We are seeking a skilled and compassionate Concurrent Review Nurse to join our team, providing telephonic clinical review and care coordination for Medicare Advantage patients. This role focuses on ensuring quality care, medical necessity, and compliance with Medicare Advantage guidelines.
- Concurrent Review: Conduct telephonic reviews of inpatient, ER and Observation services to assess medical necessity, appropriateness, and compliance with Medicare Advantage HMO policies and CMS guidelines. Cases discussed with admitting providers to validate medical need of the services.
- Care Coordination: Collaborate with healthcare providers, case managers, and patients to ensure timely and appropriate care delivery, facilitating discharge planning and transitions of care, being sure all patient’s needs are available at the moment of transfer to a lower level of care.
- Patient Advocacy: Communicate with patients to provide education, clarify treatment plans, and address concerns, ensuring a positive patient experience.
- Compliance and Documentation: Maintain accurate and timely documentation in electronic health record (EHR) systems, ensuring compliance with regulatory standards and organizational protocols.
- Minimum of 3 years of clinical nursing experience, preferably in acute care, case management, or utilization review.
- Experience with Medicare Advantage HMO plans and CMS regulations strongly preferred.
- Prior telephonic or remote nursing experience is a plus.
- Strong knowledge of utilization management principles and clinical guidelines (e.g., InterQual, Milliman).
- Excellent communication and interpersonal skills for telephonic patient and provider interactions.
- Proficiency in EHR systems and Microsoft.
- Ability to work independently, prioritize tasks, and manage time effectively in a fast-paced environment.
- Analytical skills to assess clinical documentation and make evidence-based decisions.
- Associate’s or Bachelor’s degree in Nursing (BSN preferred).
- Active, unrestricted Registered Nurse (RN) license in the state of Florida.
- Certified Case Manager (CCM) or Utilization Management Certification preferred but not required.
- No travel required.
Full-time, Monday through Friday, with occasional on-call or weekend requirements based on organizational needs.
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
To apply for the Concurrent Review Nurse position, please fill out the following form:
