Clinical Review Nurse - Prior Authorization

Centene Corporation

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. Work Location This is a fully remote role. Candidates must hold active New York State Registered Nurse (RN) licensure and be willing to work Eastern Time (ET/EST) hours. Licensure Requirement Active and unrestricted New York State Registered Nurse (RN) licensure is required for consideration. Schedule This position follows a Monday–Friday schedule from 8:30 AM to 5:00 PM Eastern Time (ET/EST), with a one‑hour assigned lunch break. Candidates must be able to work during these hours. Position Purpose: 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.

Requirements

• Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.
• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
• LPN - Licensed Practical Nurse - State Licensure required
• NYS RN Licensure required.
• Active and unrestricted New York State Registered Nurse (RN) licensure is required for consideration.
• Candidates must be able to work during these hours.
• Candidates must hold active New York State Registered Nurse (RN) licensure and be willing to work Eastern Time (ET/EST) hours.

Nice To Haves

• Knowledge of Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.

Responsibilities

• 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

Benefits

• Centene offers a 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees