[Hiring] Clinical Review Nurse @Centene Corporation

Role Description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. This position is fully remote/work from home; applicants must reside in the state of Missouri and hold an active Missouri RN licensure. The role supports our Medicaid population.

The work schedule is Monday - Friday, 8am - 5pm central time zone with 1 - 2 rotational holidays/year.

Ideally we are looking for applicants with strong clinical background, managed care and utilization management/review experience are helpful.

• Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines.
• Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
• Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care.
• Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member.
• Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered.
• Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines.
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
• Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members.
• Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines.
• Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collaborates with care management on referral of members as appropriate.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
• 2 – 4 years of related experience.
• 2+ years of acute care experience required.
• Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Requirements

• RN - Registered Nurse - State Licensure and/or Compact State Licensure for MO Medicaid is required.

Benefits

• Competitive pay.
• 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.