Concurrent Review Nurse

About Us

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients.  ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and passion for making a difference. We support a culture focused on teamwork, support, and inclusion. We offer a flexible work environment and schedules with work from home options. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees.  Additional employee paid coverage options available.  We also offer paid holidays, birthday off, and unlimited PTO as well as a 401k plan. 

Job purpose

As a Concurrent Review Nurse, you will be responsible for coordinating and overseeing the care of patients receiving inpatient medical services. Working closely with healthcare providers, patients, and their families, you will ensure that patients receive comprehensive and coordinated care, promote continuity of care, and optimize patient outcomes.

Duties and responsibilities

The role of the concurrent review nurse to provide patient advocacy through appropriate utilization of services.

Manage inpatient cases to ensure that medical care is medically necessary by conducting concurrent review and retrospective review for appropriateness of admission, level of care and determines length of stay.

Overall planner of utilization efforts to effectively manage care from admission to discharge.

Communicates with the facilities to get clinical information.
Communicates with the facilities to get coordinate discharge planning for the member.

Conduct case review based on criteria (InterQual or MCG) and makes a determination based on turnaround times established by the company. Comply with UM policies and procedures. Annual review of UM policies.

Maintains Interrater Reliability Rate at least 95% or above.

Act as clinical resources to all departments.

Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization or appropriate services to our patients.

Attend to provider and interdepartmental calls in accordance with exceptional customer service.

Ability to keep a high level of confidence and discretion when dealing with sensitive matters relating to providers and members. Always maintain strict confidentiality.

Other duties as needed.

Qualifications                                

Current licensure or certification as a Registered Nurse (RN), Licensed Vocational Nurse. depending on the jurisdiction and requirements.

CM and/or UM training and/or certification.

Strong Knowledge of Medicare, Commercial and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning.

Working knowledge of common diagnoses, procedures and diagnostic codes.

Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements models such as DRGs, Full Risk, etc.

Strong understanding of the criteria, rules and regulations around inpatient, Observation and Outpatient levels of patient management.

A high degree of self-directed organizational skills, ability to set priorities, manage multiple demands and the ability to work independently and as a part of a multidisciplinary team.

Able to work in a variety of computer programs, including InterQual, Ezcap, and Microsoft.

Five years+ clinical experience.

Prefer two (2) years+ experience in an HMO/IPA/Managed care setting is preferred and recommended.

Commitment to patient-centered care, cultural competence, and ethical practice.

Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe

Detail oriented and highly organized.

Strong ability in problem-solving

Ability to manage self-manage, strong time management skills.

Ability to work in an extremely confidential environment.

Strong written and verbal communication skills

Salary Range: 

$70,000 - $95,000 annually (LVN) depending on experience 

$85,000 - 120,000 annually (RN) depending on experience