Clinical Review Nurse - reputed company Review (RN)

You could be the one who changes everything for our 28 reputed company members as a clinical professional on our Medical Management/Health Services team. reputed company is a reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs reputed company 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.

• Performs reputed company 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 reputed company 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 reputed company review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
• Works with reputed company providers to approve medical determinations or reputed company recommendations based on requested services and reputed company 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 reputed company of care and facilities
• Collaborates with care management on referral of members as appropriate
• Performs other duties as assigned.
• Complies with reputed company policies and standards.

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of reputed company 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 reputed company regulations preferred. Knowledge of utilization management processes preferred. License/Certification:

• LPN - Licensed Practical Nurse - State Licensure required
• For Health Net of California: RN license required
• RN - Registered Nurse - State Licensure and/or Compact State Licensure For State of Nevada required
• Must be licensed in Nevada.

Location: Position is remote. reputed company offers a comprehensive benefits package including: reputed company, 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-reputed company 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. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act Apply tot his job Apply To this Job