[Hiring] NICU RN - Clinical Review Nurse - Concurrent Review @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. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

NOTE: This is a fully remote role with a focus on NICU services. Preference will be given to applicants:

• With active compact nursing licensure
• With experience in neonatal intensive care unit (NICU)
• Willing to work eastern time zone schedule

Additional Details:

• Department: PHCO UM NICU
• Business Unit: Corporate
• Schedule: Monday-Friday 8 am - 5pm ET with rotating weekends (Saturday, Sunday) and holidays

Position Purpose:

• 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

• LPN - Licensed Practical Nurse - State Licensure required
• For Health Net of California: RN license 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

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.