Centene Management Company LLC is hiring a Clinical Review Nurse - Concurrent Review

Centene Management Company LLC is seeking a Clinical Review Nurse to perform concurrent reviews for its members. You will determine overall health, evaluate medical necessity, and contribute to discharge planning according to established care policies. This role assists in validating the necessity and setting of care being delivered.

What You'll Do

• Perform concurrent reviews to determine a member's appropriate care level and setting.
• Review quality and continuity of care via acuity, resource consumption, length of stay, and discharge plans.
• Collaborate with Medical Affairs and Medical Directors to discuss member care.
• Collect, document, and maintain concurrent review findings and actions in health management systems.
• Work with healthcare providers to approve determinations or provide recommendations based on review findings.
• Assist in educating providers on utilization processes to ensure high-quality, appropriate care.
• Provide feedback to leadership on opportunities to improve appropriate level of care and medical necessity.
• Review member transfer or discharge plans to ensure timely transitions between care levels and facilities.
• Collaborate with care management to refer members as appropriate.
• Perform other assigned duties and comply with all policies and standards.

What We're Looking For

• Graduate from an Accredited School of Nursing or a Bachelor’s degree in Nursing.
• 2 – 4 years of related professional experience.
• 2+ years of acute care experience.
• LPN - Licensed Practical Nurse - State Licensure required.
• For Health Net of California: RN license required.

Nice to Have

• Clinical knowledge to determine overall health, treatment needs, and appropriate care level.
• Knowledge of Medicare and Medicaid regulations.
• Knowledge of utilization management processes.
• Experience in acute care, utilization management, medical necessity review, InterQual knowledge, and discharge planning.
• Active Indiana or compact nursing license.
• Based in the eastern time zone USA.

Technical Stack

• Health management systems.

Team & Environment

This role is within the Concurrent Review MCD department, part of the Corporate business unit.

Benefits & Compensation

• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• Flexible approach to work with remote, hybrid, field, or office schedules.
• Hourly compensation: $26.50 - $47.59 per hour.

Work Mode

This is a fully remote position.

Centene is a diversified, national organization offering competitive benefits and a fresh perspective on workplace flexibility. We are an equal opportunity employer committed to diversity, valuing the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.