Clinical Review Nurse - Concurrent Review (Healthcare)

Location: Remote within the United States, supporting Ambetter members in Georgia. Schedule: Monday-Friday, 8:00 a.m.-5:00 p.m. Eastern Time.

Salary: $27.02-$48.55 per hour.

Company

hirify.global provides healthcare services intended to make care more accessible and effective for individuals, families, and communities.

What you will do

• Perform concurrent reviews to assess members' overall health, medical necessity, appropriate care settings, and levels of care.
• Evaluate acuity, resource consumption, length of stay, quality and continuity of care, and discharge planning.
• Document review findings, discharge plans, and actions in health management systems according to utilization management policies.
• Collaborate with Medical Affairs, medical directors, care management teams, healthcare providers, and facilities.
• Approve medical determinations or provide recommendations based on requested services and clinical findings.
• Educate providers and share opportunities to improve medical necessity and appropriate levels of care.

Requirements

• Graduate from an accredited school of nursing or hold a Bachelor’s degree in Nursing.
• 2-4 years of related experience, including at least 2 years of acute care experience.
• State RN licensure is required; compact-state RN licensure is preferred. Nevada positions require the applicable state licensure.
• LPN state licensure is required.
• Knowledge of clinical assessment, treatment needs, and appropriate levels of care.
• Knowledge of Medicare and Medicaid regulations and utilization management processes is preferred.

Culture & Benefits

• Fully remote work-from-home arrangement with a weekday schedule.
• Health insurance, 401(k), stock purchase plans, tuition reimbursement, paid time off, and holidays.
• Flexible work approaches are available across remote, hybrid, field, and office environments.
• Equal opportunity workplace committed to diversity and inclusion.