Clinical Review Nurse - Concurrent Review - RN

Centene • Arlington, TX

229d • $26 - $47

About The Position

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. RN Compact/Multi-State License Required Registered Nurse Strongly Preferred. 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.

Requirements

• 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 to determine overall health and treatment needs.
• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• LPN - Licensed Practical Nurse - State Licensure required.

Responsibilities

• Performs concurrent reviews to determine member's overall health and evaluate medical necessity.
• Assists in evaluating inpatient services to validate the necessity and setting of care.
• Reviews quality and continuity of care by assessing acuity level, resource consumption, and length of stay.
• Works with Medical Affairs and/or Medical Directors to discuss member care.
• Collects, documents, and maintains concurrent review findings and discharge plans.
• Works with healthcare providers to approve medical determinations.
• Provides education to providers on utilization processes.
• Gives feedback to leadership on improving care levels and medical necessity.
• Reviews member's transfer or discharge plans for timely discharges.
• Collaborates with care management on member referrals.
• Performs other duties as assigned.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible work schedules (remote, hybrid, field, or office work)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree