Centene Management Company LLC is hiring a Clinical Review Nurse - Prior Authorization to ensure members receive appropriate, high-quality care. In this role, you will analyze prior authorization requests against national standards and benefit coverage to determine medical necessity and the appropriate level of care.
What You'll Do
- Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness in accordance with regulatory guidelines and criteria.
- Work with healthcare providers and the authorization team to ensure timely review of services so members receive authorized care.
- Coordinate with healthcare providers and interdepartmental teams to assess medical necessity.
- Escalate prior authorization requests to Medical Directors as appropriate.
- Assist with service authorization requests for member transfers or discharge plans to ensure timely movement between care levels.
- Collect, document, and maintain all member clinical information in health management systems for compliance.
- Assist with educating providers and interdepartmental teams on utilization processes to promote quality and cost-effective care.
- Provide feedback on opportunities to improve the authorization review process.
- Perform other duties as assigned.
- Comply with all policies and standards.
What We're Looking For
- Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
- 2 – 4 years of related experience.
- LPN - Licensed Practical Nurse - State Licensure.
Nice to Have
- Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service.
- Knowledge of Medicare and Medicaid regulations.
- Knowledge of utilization management processes.
- Compact License.
Team & Environment
You will join the Medical Management/Health Services team.
Benefits & Compensation
- Compensation: $26.50 - $47.59 per hour.
- Health insurance.
- 401K and stock purchase plans.
- Tuition reimbursement.
- Paid time off plus holidays.
Work Mode
This is a remote position with a flexible approach to work schedules.
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.
