Concurrent Review Nurse, Re-Admissions RN at GuideWell

About this role

All of our team members and contributors are expected to deliver results with accountability while collaborating seamlessly across boundaries. They embrace change with resilience, staying curious and learning continuously in a rapidly evolving landscape. Grounded in business understanding and comfortable with AI and digital tools, they solve problems with critical thinking and creativity. Above all, they are driven to serve—ensuring their work creates meaningful impact for members and the community we support. For leadership roles, we seek individuals who think critically, embrace a future-focused mindset, and bring intentional perspective to their work —whether managing people, leading projects, or guiding teams. Our ideal candidates operate across matrix environments, applying systems thinking and evidence-based decision-making to drive sustainable results with economic discipline. We value those who lead change with courage and conviction, building trust across teams, and orchestrating both human and AI capabilities to amplify impact. Across all roles - managing direct reports, leading projects, or advancing individual expertise - they cultivate resources, strengthen capabilities, and create conditions for people and work to thrive. Above all, they are committed to building durable value—decisions and actions today that compound organizational strength tomorrow. Job Summary: The CRN is responsible for performing medical reviews using established criteria to ensure the member is receiving care at the most appropriate level. The CRN builds relationships with facility case managers to facilitate appropriate care and discharge planning. The CRN is responsible for identifying appropriate care programs for members to ensure a smooth transition from facility to home and to decrease frequency of readmission. Essential Functions:
The essential functions listed represent the major duties of this role, additional duties may be assigned.
Serve as a point of contact for providers to assist in navigating members them through the continuum, educate regarding benefits, identify candidates for Care Programs and provide information pertaining to the network and network access
Evaluate members in the Hospital, Skilled Nursing Facility, LTAC, Acute Inpatient Rehab for benefit determination, medical necessity and appropriate level of care utilizing member benefits and InterQual or other medical necessity criteria.
Participate in weekly case review
Determine member's discharge status and identify and coordinate any additional needs and services that require ongoing Care Coordination services
Collaborate with Medical Directors, Managers, Co-workers and other departments including Case Management and Care Partners
Other duties as assigned
Required Experience: 2+ years related work experience. Experience Details: Recent (within the past 3-5 years) clinical experience in a hospital, LTAC, Rehab, SNF setting evaluating hospital benefit determination, medical necessity and appropriate level of care Related Bachelor’s degree or additional related equivalent work experience Nursing RN - Registered Nurse - State Licensure And/Or Compact State Licensure Florida Experience in one or more of the following: home health care, rehab, SNF, utilization review, discharge planning or case management Referrals for possible Case Management activities that focus on acute and non-acute services, outpatient services and/or community resources Experience with the Healthcare industry and Managed Care Experience in MS Word and Excel Moderate to heavy keying required Occasional travel within the State of Florida Preferred Experience: Bachelor’s degree Nursing, Healthcare or Business Unrestricted US RN license General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. What We Offer: As a Florida Blue employee, you will be at the heart of GuideWell ’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living. To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
Medical, dental, vision, life and global travel health insurance;
Income protection benefits: life insurance, short- and long-term disability programs;
Leave programs to support personal circumstances;
Retirement Savings Plan including employer match;
Paid time off, volunteer time off, 10 holidays and 2 well-being days;
Additional voluntary benefits available; and
A comprehensive wellness program
Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ. To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases. Annualized Salary Range: $71,200 - $115,700 Typical Annualized Hiring Range: $71,200 - $89,000 Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment. Originally posted on Himalayas