The Role
Performs concurrent utilization reviews of inpatient stays using evidence-based criteria (InterQual/MCG), determines medical necessity and level of care, coordinates with providers and payers, documents decisions per regulatory standards, escalates cases as needed, and supports quality improvement and discharge planning.
Summary Generated by Built In
Position Summary:
The Concurrent Review Nurse is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements.
Key Responsibilities:
Education & Licensure:
Palm Medical Centers is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Medical Centers makes hiring decisions based solely on qualifications, merit, and business needs at the time.
The Concurrent Review Nurse is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements.
Key Responsibilities:
- Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care.
- Evaluate clinical documentation against evidence-based criteria (e.g., InterQual®, MCG) to determine medical necessity and appropriate level of care.
- Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning.
- Communicate utilization review decisions and recommendations to providers and payers.
- Document all reviews, decisions, and communications in accordance with regulatory and organizational standards.
- Identify cases requiring escalation or peer review and follow established procedures.
- Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA.
- Participate in quality improvement initiatives and departmental meetings
Education & Licensure:
- Registered Nurse (RN) license, active and in good standing, required.
- Associate or Bachelor’s degree in nursing (BSN preferred).
- Minimum 2 years of clinical experience (e.g., med-surg, critical care).
- At least 1 year of utilization review, case management, or managed care experience preferred.
- Knowledge of InterQual®, MCG, or other clinical review guidelines.
- Familiarity with Medicare/Medicaid and commercial insurance regulations.
- Strong analytical and clinical judgment skills.
- Effective communication and negotiation skills.
- Proficient with electronic medical records (EMRs) and utilization review platforms.
- Detail-oriented with excellent organizational skills.
- Corporate Office
Palm Medical Centers is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Medical Centers makes hiring decisions based solely on qualifications, merit, and business needs at the time.
Skills Required
- Active Registered Nurse (RN) license in good standing
- Associate or Bachelor's degree in Nursing
- Bachelor of Science in Nursing (BSN)
- Minimum 2 years clinical experience (e.g., med-surg, critical care)
- At least 1 year utilization review, case management, or managed care experience
- Knowledge of InterQual or MCG clinical review guidelines
- Familiarity with Medicare, Medicaid, and commercial insurance regulations
- Proficiency with electronic medical records (EMRs) and utilization review platforms
- Knowledge of CMS guidelines, NCQA/URAC accreditation standards, and HIPAA compliance
- Strong analytical, clinical judgment, communication, negotiation, and organizational skills
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The Company
What We Do
Palm Medical Centers is a rapidly growing senior primary care leader and Medicare medical practice dedicated to providing high-quality, personalized, value-based healthcare for seniors and adults. Operating over 30 centers throughout Florida and expanding into Texas, they focus on delivering an elevated level of primary care services to ensure patient safety and improve outcomes for the aging population they serve.
