Nurse, Concurrent Review (Healthcare)

TL;DR

Nurse, Concurrent Review (Healthcare): Performing concurrent inpatient utilization reviews using InterQual criteria to determine medical necessity with an accent on clinical collaboration and regulatory compliance. Focus on managing admission and continued stay reviews and ensuring adherence to HIPAA and URAC/NCQA standards.

Location: Remote (Must hold an active unrestricted RN license in the U.S.)

Salary: $75,000 annually

Company

hirify.global is an AI-powered leader in intelligent operations and transformation serving global clients across various industries including healthcare.

What you will do

• Perform concurrent inpatient utilization reviews (admissions, continued stays, transitional care) using InterQual criteria.
• Collaborate with physicians and care teams to obtain clinical information and support level-of-care decisions.
• Maintain detailed written documentation according to company policy and regulatory guidelines.
• Ensure compliance with HIPAA, URAC, NCQA, and state/federal regulations.
• Act as a subject matter expert for Compliance Department initiatives and quality management programs.
• Facilitate resolution of escalated cases and refer complex cases to Physician Reviewers.

Requirements

• Current, active unrestricted RN license in the U.S. (USRN equivalent).
• RN graduate from an accredited school of nursing.
• Minimum 2 years of experience in an acute care setting.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint).
• Knowledge of medical necessity criteria and insurance terminology.
• Availability to work within US time zones (PST/CST).

Nice to have

• BSN degree.
• 2 years of inpatient clinical nursing, utilization management, or case management experience.
• Experience with InterQual or similar clinical decision support criteria.
• Familiarity with observation versus inpatient status determinations.

Culture & Benefits

• Medical, dental, and vision insurance.
• 401(k) with company match.
• Paid time off (PTO), holidays, and sick leave.
• Life and AD&D Insurance.
• Employee Assistance Program.