Clinical

• Clinical Review Nurse
• Concurrent Review
• J00933#26-23077 Clayton, MO Onsite Job Description Job Profile Summary

Position Purpose:

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.

Education/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:

LPN

• Licensed Practical Nurse
• State Licensure required

For Health Net of California:

RN license required 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

EEO:

"Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of

• Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

" =============

Position Purpose:

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. 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 Story Behind the Need What is the purpose of this team? What is driving this need? (ex. Backfill for FTE or CW, new project, business growth) Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative? My team does concurrent reviews for KY Medicaid's inpatient medical stays. We have two employees going out on leave for 4-5 months at the end of this year and will need help while they are out. The team is small and tight knit. It is a busy market. There is potential for upcoming hiring needs depending on how the medical leaves play out. Typical Day in the Role Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique? 19-21 reviews a day. One of the only teams within Centene that still utiilizes Care Central. Candidate Requirements Education/Certification

Required:

Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2

• 4 years of related experience.

Preferred:

BSN Licensure

Required:

LPN

Preferred:

RN Years of experience required: 2-4 years of related experience.

Disqualifiers:

no UM background

• must be tech savvy Additional qualities to look for: ICU, Med-surge, Acute Care experience preferred.

Top 3 must-have hard skills stack-ranked by importance 1 Extensive clinical background. 2 Technologically Savvy 3 Must be able to multi-task. Candidate Review & Selection Shortlisting process Candidate review & selection Interview information Onboard process and expectations

Projected Manager Candidate Review Date:

1-2 days post shortlisting

Type of Interviews:

Teams

• Cameras On Required Testing or Assessment (by Vendor): Typing test, basic computers skills test 40-50 wpm Steps