Clinical Review Nurse - Concurrent Review

Location: Remote-NC

Salary: $27.02–$48.55 per hour

Company

hirify.global connects people with healthcare services and supports more accessible and effective care.

What you will do

• Perform concurrent reviews of members to assess overall health, treatment needs, medical necessity, and the appropriate level and setting of care.
• Review acuity, resource consumption, length of stay, quality, continuity of care, and discharge plans.
• Collaborate with Medical Affairs, Medical Directors, care management teams, healthcare providers, and facilities.
• Document review findings, discharge plans, and actions in health management systems.
• Approve medical determinations or provide recommendations based on requested services and clinical guidelines.
• Educate providers on utilization processes and identify opportunities to improve care levels and medical necessity decisions.

Requirements

• Graduation from an accredited school of nursing or a Bachelor’s degree in Nursing.
• 2–4 years of related experience, including at least 2 years of acute care experience.
• State nursing licensure is required; LPN licensure is required, with RN licensure requirements applying to specified programs and states.
• Clinical knowledge of member health, treatment needs, and appropriate levels of care.
• Ability to assess inpatient services, medical necessity, utilization, and discharge planning.

Nice to have

• Knowledge of Medicare and Medicaid regulations.
• Knowledge of utilization management processes.

Culture & Benefits

• Health insurance and comprehensive employee benefits.
• 401(k) and stock purchase plans.
• Tuition reimbursement.
• Paid time off and holidays.
• Flexible remote, hybrid, field, or office work schedules where applicable.