Concurrent Review RNWhat You'll DoAs a Concurrent Review RN, you'll leverage your clinical expertise and utilization management knowledge to evaluate medical necessity, coordinate care transitions, and collaborate with healthcare teams to ensure optimal patient care.
Key Responsibilities- Promote the mission, vision, and values of P3 Health Partners.
- Perform telephonic and onsite utilization reviews, including prior authorization, concurrent review, and transition of care evaluations.
- Review and approve services within scope of authority and escalate cases requiring additional review when appropriate.
- Apply evidence-based review criteria, including:
- Health plan benefits
- CMS guidelines
- Local and National Coverage Determinations (LCD/NCD)
- InterQual and MCG criteria
- Utilize clinical judgment to assess medical necessity, level of care, and appropriate service utilization.
- Collaborate with hospitals, providers, and internal stakeholders to support discharge planning and care transitions.
- Request and review additional clinical documentation to support utilization review decisions.
- Escalate complex cases and medical necessity questions to the Medical Director as needed.
- Coordinate care with physicians, specialists, emergency department personnel, patients, and families.
- Partner with provider network teams and Medical Management departments to align care plans and support positive patient outcomes.
- Educate providers and clinical staff regarding utilization management processes, criteria, and requirements.
- Serve as a clinical resource and subject matter expert for non-clinical team members.
- Identify opportunities to close care gaps and improve patient outcomes.
- Accurately document all clinical reviews, communications, and decisions within designated systems.
What Makes You SuccessfulYou are a highly skilled clinician with a strong understanding of utilization management, care coordination, and evidence-based decision making. You are comfortable working independently while building strong relationships across healthcare settings.
Core Competencies- Strong clinical knowledge of acute, post-acute, and transitional care management.
- In-depth understanding of utilization management principles and medical necessity review processes.
- Experience applying evidence-based criteria, including InterQual, MCG, and CMS guidelines.
- Excellent communication skills with the ability to interact effectively with physicians, hospital personnel, patients, and families.
- Strong critical thinking, assessment, and problem-solving abilities.
- Ability to navigate complex or sensitive discussions regarding level of care and service authorization decisions.
- Exceptional organizational skills with the ability to manage multiple priorities and deadlines.
- Proficiency with Microsoft Office applications and medical management software platforms.
- Ability to work independently while collaborating effectively within interdisciplinary teams.
- Adaptability and commitment to continuous learning in an evolving healthcare environment.
QualificationsRequired- Graduate of an accredited School of Nursing.
- Active Registered Nurse (RN) license in Oregon with the ability to obtain and maintain licensure in multiple states.
- Minimum of four (4) years of clinical nursing experience.
- Minimum of two (2) years of experience in a managed care, Medicare Advantage, or HMO environment.
- Experience conducting medical necessity reviews and applying evidence-based clinical guidelines.
Preferred- Bachelor of Science in Nursing (BSN).
- Previous Emergency Department (ED) experience.
- Previous Intensive Care Unit (ICU) experience.
- Experience in Case Management and/or Utilization Management.
- Experience working with InterQual, MCG, CMS guidelines, and transitions of care programs.
Schedule Hours & Work Location- Monday - Friday, 8 AM - 5 PM PST
- This role offers a hybrid work arrangement. Candidates will follow our hybrid schedule, working in office three days per week.
Salary Range: $90,000 - $100,000 annually
The posted salary range reflects P3 Health Partners' good-faith estimate for this role at the time of posting. Placement within the range will be based on qualifications, experience, education, geographic location, and internal equity considerations. In addition to base salary, eligible employees may have access to a comprehensive benefits package and other compensation opportunities.
