[Hiring] Clinical Review Nurse @Centene Corporation

Role Description

Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

• This fully remote role requires an active New York RN license and the ability to work Monday through Friday, 8:30 AM to 5:00 PM ET, with a one-hour lunch break.
• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
• Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
• Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member.
• Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care.
• Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
• Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members.
• Provides feedback on opportunities to improve the authorization review process for members.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• Bachelor’s degree in Nursing (BSN) or graduation from an accredited school of nursing, plus 2 to 4 years of related experience.
• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Requirements

• For Fidelis Plan Only: A clinical degree as a healthcare professional is required along with the appropriate license. Examples include Nursing, PT and OT.

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.