[Hiring] Senior RN Clinical Review Nurse - Prior Authorization @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.

This position supports our Fidelis state plan and requires NY RN Licensure.

Position Purpose:

• Routinely reviews more challenging 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.
• Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
• Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria.
• Collaborates with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
• Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care.
• Manages service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Provides feedback on opportunities to improve the authorization review process for members.
• Manages as appropriate with healthcare providers, utilization management team, and care management team to assess medical necessity of care.
• Partners with interdepartmental teams on projects within utilization management as part of the clinical review team.
• Manages and reviews all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
• Provides education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members.
• Develops in-depth knowledge of the prior authorization process and acts as a trainer to other team members.
• 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.
• 4 – 6 years of related experience.
• Advanced clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
• Strong knowledge of Medicare and Medicaid regulations preferred.
• Strong knowledge of utilization management processes preferred.

Requirements

• LPN - Licensed Practical Nurse - State Licensure required.
• This position supports our Fidelis state plan and requires NY RN Licensure.

Benefits

• Pay Range: $30.58 - $55.09 per hour.
• Comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a 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.