Under the general supervision of the Director of Health Services, the Concurrent Review Nurse is responsible for ensuring the delivery of medically necessary, high-quality, and cost-effective care. This is achieved through the review of inpatient admissions, outpatient precertification, and prior authorization requests, using established medical policies, evidence-based guidelines, and managed care standards.

Essential Duties and Responsibilities

• Lead, train, and support both clinical and non-clinical staff in accordance with Leon Health’s policies and procedures to ensure efficient and effective performance.
• Monitor and respond to incoming calls and written inquiries from members, providers, and internal departments.
• Oversee the quality, accuracy, and timeliness of prior authorization reviews and ensure appropriate prioritization.
• Enter service requests and determination data into the appropriate systems in compliance with regulatory requirements and organizational policies.
• Review clinical documentation for precertification and concurrent (ongoing) reviews.
• Perform on-site and/or telephonic reviews to determine the appropriateness of inpatient and outpatient care settings, using medical policies, CMS guidelines, and industry standards.
• Conduct medical and behavioral health (BH) reviews for pre- and post-service authorization requests.
• Issue authorizations for inpatient admissions, outpatient services, and post-service requests to providers, facilities, and members as applicable.
• Refer complex cases to a Medical Director or Behavioral Health Practitioner when additional clinical evaluation is required.
• Ensure all documentation is complete, accurate, and clearly supports authorization decisions.
• Process denial determinations in compliance with regulatory standards and internal policies.
• Maintain up-to-date census reports, daily notes, and authorization records, including tracking admissions and discharges.
• Collaborate with healthcare providers to obtain necessary clinical documentation for medical necessity determinations.
• Work with providers to proactively identify discharge needs and assist in care planning.
• Facilitate smooth care transitions across the healthcare continuum by coordinating with facilities and the Care Management team.

Education

• Bachelor’s degree in Nursing required

Experience

• Minimum of two (2) years of experience in clinical review or utilization management

Language Skills

• Bilingual in English and Spanish (required)