临床审查护士 - 同步审查
Clinical Review Nurse-Concurrent Review
职位职责：进行同步审查，包括评估成员的整体健康状况，审查所提供的护理类型，评估医疗必要性，并根据护理政策和指南参与出院计划。协助评估住院服务，以验证为成员提供的护理的必要性和护理设置。
关键信息：有2个职位空缺，远程/居家办公，无需出差，必须能够按照东部时区时间工作，每周工作时间为周二至周六或周日到周四，包含轮班节假日（每年约3次）。优先考虑拥有紧凑型护士执照，并具有至少2年急性护理临床经验的候选人。熟悉利用管理及医保和Medicaid法规者优先。将支持医保住院同步审查。
- 对成员进行同步审查，以确定适当的护理和护理设置，评估整体健康状况和适当的护理级别
- 通过审查成员的病情严重程度、资源消耗、住院时长和出院计划来评估护理质量和连续性
- 根据需要与医疗事务部和/或医疗主任讨论成员的护理情况
- 收集、记录并维护同步审查结果、出院计划以及在成员病历中采取的行动，根据利用管理政策和指南录入健康管理系统
- 与医疗保健提供者合作，批准医疗决定或根据所请求的服务和同步审查结果提供建议
- 协助向提供者提供有关利用流程的教育，以确保为成员提供高质量的适当护理
- 根据临床政策和指南，向领导层提供关于改善适当护理级别和医疗必要性的反馈
- 审查成员的转院或出院计划，确保在不同护理级别和设施之间及时出院
- 与护理管理协作，根据需要转介成员
- 执行其他指派的任务
- 遵守所有政策和标准
教育/经验：需毕业于认证的护理学校或获得护理学士学位，并具有2-4年相关经验。要求至少2年以上急性护理经验。
优先考虑具备成员整体健康状况评估能力，包括治疗需求和适当护理级别的临床知识。
优先考虑熟悉医保和Medicaid法规。
查看英文原文
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.
Key Details: 2 positions available, remote/work from home, no travel, must be able to work eastern time zone hours either Tuesday - Saturday or Sunday - Thursday with rotational holidays (approximately 3/year). Prefer a compact RN licensure with a minimum of 2 years acute care clinical experience. Knowledge of Utilization Management and Medicare and Medicaid regulations preferred. Will support Medicaid inpatient concurrent review.
- 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.
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
- RN - Registered Nurse - State Licensure and/or Compact State Licensure For State of Nevada required
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Originally posted on Himalayas