Clinical Review Nurse - Concurrent Review

Location: Remote-NC; Monday through Friday with a rotating weekend schedule

Pay: $27.02–$48.55 per hour

Company

hirify.global connects people with the care they need and works to make healthcare more accessible and effective.

What you will do

• Perform concurrent reviews to assess members’ overall health, medical necessity, appropriate care settings, acuity, resource use, and length of stay.
• Review and document care findings, discharge plans, and actions in health management systems.
• Coordinate with Medical Affairs, Medical Directors, healthcare providers, and care management on member care and referrals.
• Approve medical determinations or provide recommendations based on requested services and review findings.
• Review transfer and discharge plans to support timely movement between levels of care and facilities.
• Educate providers on utilization processes and provide leadership feedback on opportunities to improve care levels and medical necessity.

Requirements

• Graduation from an accredited school of nursing or a Bachelor’s degree in Nursing.
• At least two years of acute care nursing experience required.
• Two to four years of related experience.
• LPN state licensure or RN state and/or compact-state licensure required.
• Clinical knowledge sufficient to assess treatment needs and the appropriate level of care.
• Knowledge of Medicare and Medicaid regulations and utilization management processes is preferred.

Nice to have

• Previous utilization management or case management experience.
• Knowledge of Medicare and Medicaid regulations.
• Knowledge of utilization management processes.

Culture & Benefits

• Health insurance, 401(k), and stock purchase plans.
• Tuition reimbursement, paid time off, and holidays.
• Flexible work approaches, including remote, hybrid, field, and office schedules.
• Equal opportunity workplace committed to diversity and inclusion.