Concurrent Review Nurse-Castellana
MMM Holdings
San Juan, PR, US
hace 11 horas

Job Description

POSITION TITLE : Concurrent Review Nurse (CRN)


Manages the inpatient utilization of healthcare resources and develops, coordinates and implements the discharge plan, in an effort to ensure that the coordination and continuity of care results in optimal patient outcomes.


1.Performs daily visits to acute, SNF, and Rehabilitation inpatient facilities to concurrently review admissions and continued stay to determine appropriate Utilization, Quality Assurance, Risk Management and Discharge Planning Needs.

2.Validates all inpatient admissions for appropriate level of care within forty-eight (48) hours of admission on weekdays and within seventy-two (72) hours of admission on weekends.

3.Develops and documents a discharge plan on each inpatient within forty eight (48) hours of having performed the first concurrent review at notification admission cases.

4.On a daily basic concurrently reviews all inpatient care, on site or telephonically to validate appropriateness of services, lengths of stay and levels of care, utilizing nationally recognized guidelines, protocols an critical pathways including, but not limited to Inter -Qual guidelines.

5.Develops, monitors, modifies and implements individualized transfer or discharge plans, to assure a timely discharge between levels of care and between facilities.

6.Communicates regularly with the attending Physician / Hospital staffs regarding the patient’s status, any identified problems related to appropriateness of services, quality of care, or issues that may impact a timely discharge.

7.Refer appropriate problems to the Plan’s Medical Director for intervention and resolution and confers daily regarding patient and physician related issues.

8.Performs concurrent quality review and reports identified quality issues to the health plan’s and hospital’s Quality Improvement Departments.

9.Initiates the initial discharge assessment to all admission cases.

10.Initiates referrals to DPU / Ambulatory Case Management utilizing the health plan’s criteria for referrals.

11.Researches community resources available to members, assesses the financial implications of a specific discharge plan, and develops a plan to most appropriately access those resources as well as covered benefits.

12.Identifies aberrant in patient days, documents, and codes and reports the data to the Utilization Management Data Entry Coordinator.

13.Captures required in patient utilization data and forwards the information, on a daily basis, to the Utilization Management Data Entry Coordinator.

14.Prepares and submits to the Health Services Department / UM Medical Care Manager a monthly report of activities performed.

15.Attends all Utilization Management staff meetings.

16.Performs additional duties relevant to the position as requested by the ProHealth Inpatient Medical Care Manager.


Current R.N. permanent license in Puerto Rico

Bachelor’s degree in Nursing or equivalent in a health care related field preferred.

Five years clinical acute care hospital experience; ICU, Emergency Medicine Department, Medical / Surgical Department.

One to three years experience in a manager care, health services setting preferred.


1.Must possess a current Puerto Rico driver’s license and is able to commute to various facilities on any given day within 50 miles of the worksite office.

2.Must have ability to work as a team player with excellent bilingual, verbal and written communication skills.

3.Knowledge of community healthcare related resources preferred.

4.Strong interpersonal skills.

5.Independent and a self starter.

6.Ability to analyze and solve problems

7.Familiarity with State Federal Governmental regulations and national accrediting agency requirement preferred.

8.Availability to work flexible schedules including weekends and holidays.

9.Must be computer literate.

10.Must be able to sit and stand for long periods of time with sufficient mobility to perform all job duties in the hospital an office environment.

11.Performs tasks requiring independent knowledge judgment in addition to instructions and procedures provided.

12.Must be able to function with frequent interruptions, accept change and be able to prioritize tasks efficiently when faced with competing demands.


Fully Bilingual. Ability to read, analyze, and interpret general business periodicals, operating and maintenance instructions, procedure manuals, professional journals, technical procedures, or governmental regulations.

Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.


Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.

Ability to apply concepts of basic algebra and geometry. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.


Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.


Requires sitting and standing associated with normal office environment. Regularly talks and hears. This position requires that weight be lifted or force be exerted up to 10 pounds.


Normal office environment. The noise is typically moderate. Evening or weekend work, as necessary.

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.

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