Clinical Review Nurse - Concurrent Review

Centene Corporation • Remote-MO, MO

1d • $27 - $49 • Remote

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. Applicants for this role must have a compact nursing license and will have the flexibility to work remotely from their home anywhere in the Eastern or Central time zone. The work schedule will be Monday – Friday, 8am – 5pm, Central with a rotating weekend / holiday schedule as needed. An RN with previous Post Acute experience is strongly preferred.

Requirements

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
• 2+ years of acute care experience required.
• LPN - Licensed Practical Nurse - State Licensure required

Nice To Haves

• Compact nursing license
• An RN with previous Post Acute experience is strongly preferred.
• 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.

Responsibilities

• 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.

Benefits

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• a flexible approach to work with remote, hybrid, field or office work schedules.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level