New

Clinical Review Nurse - Concurrent Review

Spectraforce Technologies

United States, North Carolina, Raleigh

500 West Peace Street (Show on map)

Oct 22, 2026

Title: Clinical Review Nurse - Concurrent Review

Location: Remote, Source from EST preferred but will consider CST

Duration: 6 months

Shift: Eastern 8-5 with expected weekend and holiday coverage based off the team needs. This is usually every 4-5 th weekend but this can change. Also working holidays are expected under a rotated schedule

Responsibilities:

Performs 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. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
Performs concurrent reviews of members for appropriate care and setting to determine overall health and appropriate level of care
For a UM CCR team, our primary focus is delivering timely, accurate, and clinically appropriate authorization reviews while maintaining compliance, quality, and positive member outcomes. Based on our UM program requirements and CCR operational expectations, several key initiatives drive success.

14 per day on average, 2.12 per hour. Weighted productivity about 95% along with audit scores above 95%Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
Assists with providing education to providers on utilization processes to ensure high-quality appropriate care to members
Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collaborates with care management on referral of members as appropriate

Candidate Requirements
Education/Certification	Required: Accredited School of Nursing or Bachelor's degree in Nursing	Preferred:
Licensure	Required: LPN/RN	Preferred:
Years of experience required: 2 - 4 years of related experience. 2+ years of acute care experience required/UM or managed care exp preferred Disqualifiers: Additional qualities to look for:
Top 3 must-have hard skills stack-ranked by importance	1	Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
2	Knowledge of Medicare and Medicaid regulations preferred.
3	Knowledge of utilization management processes preferred.