Medical Review Nurse (RN)

Job Description: JOB SUMMARY

Concurrent Rev Nurse RN
The CRN is responsible for performing medical reviews using established criteria to ensure the member is receiving care at the
most appropriate level. The CRN builds relationships with facility case managers to facilitate appropriate care and discharge
planning. The CRN is responsible for identifying appropriate care programs for members to ensure a smooth transition from
facility to home and to decrease frequency of readmission.

Essential Functions
The essential functions listed represent the major duties of this role, additional duties may be assigned.
Serve as a point of contact for providers to assist in navigating members them through the continuum, educate
regarding benefits, identify candidates for Care Programs and provide information pertaining to the network and
network access
20%
Evaluate members in the Hospital, Skilled Nursing Facility, LTAC, Acute Inpatient Rehab for benefit
determination, medical necessity and appropriate level of care utilizing member benefits and InterQual or other
medical necessity criteria.
30%
Participate in weekly case review 5%
Determine member's discharge status and identify and coordinate any additional needs and services that require
ongoing Care Coordination services 30%
Collaborate with Medical Directors, Managers, Co-workers and other departments including Case Management and
Care Partners 10%
Other duties as assigned 5%
Total Percentage: %100

Job Requirements
Knowledge of medical terminology
Experience with prior authorization
Experience applying nationally recognized criteria, including InterQual
Knowledge of Medicare regulations and guidelines
Computer skills, including ability to use Microsoft Office suite
Previous experience within a call-center environment
Ability to navigate through multiple systems and screens to resolve authorization or medical review requests
Talking and typing simultaneously
Effective time management skills
Effective interpersonal and communication skills
Ability to use electronic medical record and claims systems
Problem solving abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Work respectfully and positively with others
Ability to manage multiple projects and prioritize work tasks to adhere to deadlines and identified time frames
Ability to think analytically and make decisions
Ability to manage large workload

Additional Required Qualifications:
Experience in one or more of the following: home health care, rehab, SNF, utilization review, discharge planning or case
management
Referrals for possible Case Management activities that focus on acute and non-acute services, outpatient services and/or
community resources
Experience with the Healthcare industry and Managed Care
Experience in MS Word and Excel
Moderate to heavy keying required

Required Experience:
2+ years related work experience
Recent (within the past 3-5 years) clinical experience in a hospital, LTAC,
Rehab, SNF setting evaluating hospital benefit determination, medical
necessity and appropriate level of care

Required Education:
Related Bachelor s degree or additional related
equivalent work experience Nursing

Required Licenses and Certifications
RN - Registered Nurse - State Licensure
And/Or Compact State Licensure - Florida


FLSA Classification: Non Exempt
Sponsorship/Visa Eligibility: No
Client Issued Equipment: (Y/N)- Yes Equipment mailed
Remote/Hybrid/Onsite: Remote
Background Requirement: Standard with certification
Interview Comments: MS teams

When Submitting resumes include the below-
Institution Name (ex. University of Florida)
Degree Type (ex. Bachelor of Science)
Concentration (ex. Computer Science)
Completion Status (ex. Complete, Incomplete, or In-progress)
Comments for Suppliers: -Do not focus on case management
-Focus on insurance payer or Hospital UM