Summary: Work Mode: 100% Remote Duration: 6 months, possible extension Shift: Sunday, Monday, Tuesday, Wednesday OR Wednesday, Thursday, Friday, Saturday Work hours: 7am - 6pm EST Responsibilities: Perform concurrent 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. Review quality and continuity of care by assessing acuity level, resource consumption, length of stay, and discharge planning of members. Collaborate with Medical Affairs and/or Medical Directors to discuss member care being delivered. Collect, document, and maintain concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines. Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings. Assist with providing education to providers on utilization processes to ensure high-quality, appropriate care to members. Provide feedback to leadership on opportunities to improve appropriate level of care and medical necessity based on clinical policies and guidelines. Review member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities. Collaborate with care management on referral of members as appropriate. Promote the quality and cost-effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews. Perform other duties as assigned. PERFORMANCE EXPECTATIONS: 95% weighted productivity, 2.1 reviews per hour (14 per day), 90% audit scores, and 100% TAT. Requirements: Graduate from an Accredited School of Nursing. Nursing License with state of Georgia or Compact licensure. Minimum 2 years of acute care experience required. Concurrent Review Utilization Management Experience in a Medicaid/Marketplace health plan. Experience with Interqual. Knowledge of healthcare and managed care. Preferred Skills: BSN/CCM. Compact licensure preferred. Computer skills (Word, Excel, Interqual experience). Experience with reading Electronic Medical Records. Good written and verbal communication skills. Team player, calm under stress, motivated, and able to multi-task.