Centene is seeking a Clinical Review Nurse to join our team, focusing on prior authorization requests. You will conduct clinical reviews to determine medical necessity and the appropriate level of care, providing recommendations to promote quality and cost-effective medical care while supporting our Duals team.
What You'll Do
- Analyze all prior authorization requests to determine medical necessity of service and appropriate level of care.
- Perform medical necessity and clinical reviews of authorization requests.
- Work with healthcare providers and the authorization team to ensure timely review of services.
- 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 a member’s transfer or discharge plans.
- Collect, document, and maintain all member’s clinical information in health management systems.
- Assist with providing education to providers and/or interdepartmental teams on utilization processes.
- Provide feedback on opportunities to improve the authorization review process.
What We're Looking For
- Graduation from an Accredited School of Nursing or a 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.
Team & Environment
You will support the Duals team within the broader Medical Management/Health Services team.
Benefits & Compensation
- Compensation range: $27.02 - $48.55 per hour.
- Health insurance.
- 401K and stock purchase plans.
- Tuition reimbursement.
- Paid time off plus holidays.
- Flexible approach to work with remote, hybrid, field, or office work schedules.
Work Mode
This is a fully remote position.
Centene is an equal opportunity employer.
