Nurse, Concurrent Review

Performs concurrent inpatient utilization review using InterQual criteria to determine medical necessity for admissions, continued stays, and transitional care reviews (SNF, IRF, LTACH). Engages in clinical collaboration with attending physicians, hospitalists, and care teams to discuss determinations and support appropriate level-of-care decisions. Facilitates resolution of escalated cases and refers to Physician Reviewers or Medical Directors per guidelines. Maintains documentation per policy and ensures compliance with URAC, NCQA, HIPAA, and state/federal regulations. Collaborates with client personnel, provides quality customer service, and participates in the Quality Management Program. Schedule is 7AM–5PM PST / 9AM–7PM CST Monday–Friday with flexibility for weekends or alternative hours based on business needs.

RN graduate from an accredited school of nursing (BSN preferred). Current, active unrestricted RN license in a state or territory of the U.S. Two (2) years of experience in an acute care setting (required). Two (2) years of inpatient clinical nursing, utilization management, or case management experience (preferred). Experience with InterQual or similar evidence-based clinical decision support criteria (preferred). Familiarity with inpatient level-of-care criteria, observation vs. inpatient status, and transitional care planning (preferred). Working knowledge of medical necessity criteria and payer-specific utilization review requirements. Proficient in Microsoft Office (Word, Excel, PowerPoint). Strong organizational, time management, and critical thinking skills.